What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

The immediate treatment for adrenal crisis consists of intravenous hydrocortisone 100 mg bolus followed by 200 mg/24 hours as continuous infusion, along with fluid resuscitation using normal saline (10-20 ml/kg; maximum 1,000 ml). 1

Initial Management

1. Immediate Interventions:

   • Administer hydrocortisone 100 mg IV immediately as bolus dose 1
   • Begin fluid resuscitation with normal saline 10-20 ml/kg (maximum 1,000 ml) 1
   • Start maintenance hydrocortisone as 200 mg/24h continuous infusion OR 50-100 mg IV every 6 hours 1

2. Dosing Considerations:

   • For children, weight-based dosing should be used 1:
     • Up to 10 kg: 2 mg/kg IV induction, then 25 mg/24h
     • 11-20 kg: 2 mg/kg IV induction, then 50 mg/24h
     • Over 20 kg (prepubertal): 2 mg/kg IV induction, then 100 mg/24h
     • Over 20 kg (pubertal): 2 mg/kg IV induction, then 150 mg/24h

Ongoing Management

• Continue hydrocortisone until shock resolution or ICU discharge 1
• Continuous IV infusion is the only administration mode that consistently achieves cortisol concentrations in the range observed during major stress 2
• Address the precipitating cause (most commonly infections) 3
• Monitor for clinical improvement:
  • Resolution of hypotension
  • Improvement in mental status
  • Decrease in fever

Transition to Maintenance Therapy

• Once stabilized, transition to oral maintenance therapy 1
• For patients already on maintenance therapy, return to their regular dose after tapering:
  • Double or triple the maintenance dose initially
  • Taper back to maintenance dose over 5-10 days as stress resolves 1
• Standard maintenance therapy typically consists of hydrocortisone 10-30 mg daily in divided doses or equivalent prednisone 5-10 mg daily 1, 4

Clinical Presentation of Adrenal Crisis

Adrenal crisis typically presents with:

• Profound impairment of well-being 3
• Hypotension/shock 1, 3
• Nausea and vomiting 3
• Fever 1, 3
• Weakness, muscle/joint pain, drowsiness 5
• Altered mental status 1

Prevention Strategies

• Patient education on stress dosing during illness 1
• Provide emergency injectable steroids and instructions for use 1, 3
• Medical alert bracelet/card indicating adrenal insufficiency 1
• Increase glucocorticoid doses during illness or stress:
  • Double or triple maintenance dose during minor illness 1
  • For severe stress (major surgery, trauma), use IV hydrocortisone 50-100 mg every 6-8 hours 1

Common Pitfalls and Caveats

• Delayed recognition and treatment can lead to unnecessary mortality 6
• Inadequate dosing during stress situations is common - patients and physicians are often reluctant to increase glucocorticoid doses appropriately 6
• Medications that induce CYP3A4 may increase hydrocortisone metabolism, requiring higher doses 1
• Recent etomidate administration can suppress cortisol production and should be considered when evaluating adrenal function 1
• Gastrointestinal illness is the most common precipitant for adrenal crisis, which can impair oral medication absorption 6

Adrenal crisis is a life-threatening emergency with an estimated incidence of 5-10 adrenal crises per 100 patient-years and a mortality rate of approximately 0.5 per 100 patient-years 3. Early recognition and prompt treatment are essential to reduce morbidity and mortality.