What is the most appropriate medication for a patient with adrenal insufficiency and septic shock who is hypoglycemic and unresponsive to fluid and vasopressor therapy?

From the Guidelines

The most appropriate medication for a patient with adrenal insufficiency and septic shock who is hypoglycemic and unresponsive to fluid and vasopressor therapy is hydrocortisone. The recommended regimen is intravenous hydrocortisone at a dose of 200 mg per day 1, as this has been suggested by the Surviving Sepsis Campaign guidelines for patients with septic shock that is not responsive to fluid and vasopressor therapy. For the hypoglycemia, immediate administration of intravenous dextrose (D50W, 25-50 mL) is necessary, followed by continuous glucose infusion to maintain normoglycemia. In patients with adrenal insufficiency experiencing septic shock, the body cannot mount an appropriate stress response due to inadequate cortisol production. Hydrocortisone helps restore vascular tone, increases sensitivity to catecholamines, and improves blood pressure. It also helps regulate glucose metabolism, addressing the hypoglycemia that often accompanies adrenal crisis. Some studies suggest that hydrocortisone may be more effective than other corticosteroids in reversing shock in septic patients 1. However, the task force suggests against using the adrenocorticotropic hormone stimulation test to identify adults with septic shock who should receive hydrocortisone 1. Once the patient stabilizes, they should transition to maintenance glucocorticoid therapy, typically oral hydrocortisone, with appropriate stress dosing protocols for future illnesses or procedures. Key points to consider in the management of such patients include:

• The use of low-dose IV hydrocortisone for at least 3 days at full dose, or longer, in adult patients with septic shock that is not responsive to fluid and moderate to high-dose vasopressor therapy 1
• The potential benefits of hydrocortisone in improving hemodynamic stability and reducing mortality in septic patients 1
• The importance of monitoring for potential side effects, such as hyperglycemia and hypernatremia, and adjusting the treatment regimen as needed 1

From the FDA Drug Label

ACTIONS Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. The most appropriate medication for a patient with adrenal insufficiency and septic shock who is hypoglycemic and unresponsive to fluid and vasopressor therapy is hydrocortisone.

• The patient's low cortisol level indicates adrenal insufficiency, which can be treated with hydrocortisone as a replacement therapy 2.
• Hydrocortisone can help address the patient's hypoglycemia and septic shock by replacing the deficient cortisol and providing anti-inflammatory effects.
• The patient's low normal Na and high normal K levels do not directly influence the choice of hydrocortisone as the primary treatment for adrenal insufficiency.

From the Research

Diagnosis and Treatment of Adrenal Insufficiency in Septic Shock

The patient's condition, characterized by septic shock unresponsive to fluids and vasopressors, low normal sodium, high normal potassium, low cortisol, and hypoglycemia, suggests adrenal insufficiency. The appropriate medication for this condition is:

• Hydrocortisone, as it is a glucocorticoid that can help replace the deficient cortisol and improve the patient's response to septic shock 3, 4, 5.
• The use of hydrocortisone in septic shock is supported by studies that demonstrate its effectiveness in reducing the duration of shock, although its impact on mortality is inconsistent 4, 5.
• Fludrocortisone, a mineralocorticoid, may also be considered for replacement therapy in patients with adrenal insufficiency, but it is not the primary choice for septic shock 6.
• ACTH (adrenocorticotropic hormone) stimulation test may be used to diagnose adrenal insufficiency, but it is not a treatment option.
• Saline is not a suitable choice as it does not address the underlying adrenal insufficiency.

Key Considerations

• The diagnosis of relative adrenal insufficiency (RAI) or critical illness-related corticosteroid insufficiency (CIRCI) is challenging, and the decision to start steroid supplementation should be based on clinical judgment and laboratory results 3, 5.
• The optimal dosing and duration of corticosteroid therapy in septic shock remain controversial, and further research is needed to guide clinical practice 5.