What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

The immediate treatment for adrenal crisis requires prompt administration of hydrocortisone 100 mg IV bolus followed by either 50 mg IV every 6 hours or continuous infusion of 200 mg/24 hours, along with fluid resuscitation using normal saline (10-20 ml/kg; maximum 1,000 ml). 1

Initial Management

1. Immediate interventions:

   • Hydrocortisone 100 mg IV bolus immediately 1
   • Fluid resuscitation with normal saline 10-20 ml/kg (maximum 1,000 ml) 1
   • Continuous monitoring of vital signs

2. Maintenance therapy:

   • Continue hydrocortisone as either:
     • 50 mg IV every 6 hours, or
     • 200 mg/24 hours as continuous infusion 1
   • Continue until shock resolution or ICU discharge 1

Pharmacological Considerations

Hydrocortisone is the preferred glucocorticoid for adrenal crisis due to its rapid onset of action. Following IV administration, demonstrable effects are evident within one hour 2. The highly water-soluble sodium succinate ester of hydrocortisone permits immediate intravenous administration of high doses in a small volume of diluent, which is crucial when rapid high blood levels are required 2.

While dexamethasone can be used, it almost completely lacks the sodium-retaining properties of hydrocortisone 3, which may be disadvantageous in adrenal crisis where mineralocorticoid effects are beneficial for managing hypotension.

Weight-Based Dosing

For pediatric patients, weight-based dosing should be used 1:

• Up to 10 kg: 2 mg/kg IV induction, then 25 mg/24h maintenance
• 11-20 kg: 2 mg/kg IV induction, then 50 mg/24h maintenance
• Over 20 kg (prepubertal): 2 mg/kg IV induction, then 100 mg/24h maintenance
• Over 20 kg (pubertal): 2 mg/kg IV induction, then 150 mg/24h maintenance

Ongoing Management

After initial stabilization:

• Continue hydrocortisone until the precipitating cause is resolved 1, 4
• Taper back to maintenance dose over 5-10 days once stress resolves 1
• Investigate and treat the underlying trigger (most commonly infections) 4, 5

Prevention of Future Crises

Patient education is critical for preventing future adrenal crises 4, 6:

• Stress dosing during illness (double or triple maintenance dose) 1
• Use of emergency injectable steroids
• When to seek medical attention
• Importance of medical alert bracelet/card 1

Clinical Pearls and Pitfalls

• Pitfall: Delayed recognition and treatment significantly increases mortality risk 7
• Pitfall: Medications that induce CYP3A4 may increase hydrocortisone metabolism, requiring higher doses 1
• Pitfall: Recent etomidate administration can suppress cortisol production and should be considered when evaluating adrenal function 1
• Pearl: Continuous IV hydrocortisone infusion has been shown to be superior to intermittent bolus administration in maintaining appropriate cortisol levels during major stress 8
• Pearl: Gastrointestinal illness is the most common precipitant for adrenal crisis, so patients should be particularly vigilant with stress dosing during these episodes 7

Recent research supports continuous IV hydrocortisone infusion of 200 mg over 24 hours, preceded by an initial bolus of 50-100 mg, as the optimal approach for maintaining cortisol concentrations in the required range during major stress 8.