What is the management approach for a patient with adrenal insufficiency, hypotension, and elevated trough cortisol levels?

Management of Adrenal Insufficiency with Hypotension and Elevated Trough Cortisol

Despite elevated trough cortisol levels, a patient with symptoms of adrenal insufficiency including hypotension should receive immediate high-dose glucocorticoid treatment as this represents relative adrenal insufficiency, where cortisol levels may be normal or even high but insufficient for the physiological stress. 1

Initial Management

• Administer hydrocortisone 100 mg intravenously immediately, followed by continuous infusion of 200 mg/24 hours 1
• Provide rapid volume resuscitation with 3-4 L isotonic saline or 5% dextrose in isotonic saline with an initial infusion rate of approximately 1 L/hour 1
• Monitor hemodynamic parameters and serum electrolytes frequently to avoid fluid overload 1
• Consider ICU or high-dependency unit admission depending on severity 1

Understanding Relative Adrenal Insufficiency

• Adrenal crisis symptoms and signs can occur in physiologically stressed patients while plasma cortisol levels are normal or even high, recognized as "relative adrenal insufficiency" 1
• During physiological stress (like illness, surgery, trauma), cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 1
• Patients with comorbidities (especially asthma and diabetes) are more vulnerable to adrenal crisis 1

Continued Management After Initial Stabilization

• Once hemodynamically stable and able to take oral medications, transition to oral hydrocortisone at double the usual maintenance dose (e.g., if usual dose is 10-5-5 mg, increase to 20-10-10 mg) 1
• Continue doubled oral dose for 48 hours to 1 week, depending on clinical recovery 1
• If patient remains unstable, continue intravenous hydrocortisone infusion 1
• Ensure mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg daily) is restarted when hydrocortisone dose falls below 50 mg/day for patients with primary adrenal insufficiency 1, 2

Monitoring Response to Treatment

• Assess blood pressure, heart rate, and clinical symptoms frequently during initial resuscitation 1
• Monitor serum electrolytes (sodium, potassium) 3
• For long-term management, aim for plasma renin activity in the upper normal range to ensure adequate mineralocorticoid replacement 2
• Assess for signs of over-replacement (hypertension, edema, hypokalemia) or under-replacement (persistent fatigue, hypotension, hyperkalemia) 3, 2

Prevention of Future Episodes

• Educate patient on self-management of their condition 1, 4
• Provide emergency hydrocortisone injection kit (100 mg) for self-administration during emergencies 1, 4
• Ensure patient wears medical alert identification and carries a steroid alert card 1
• Instruct on stress dosing protocols: double or triple maintenance dose during minor illness, injury, or stress 5, 4
• Schedule regular follow-up visits to assess adequacy of replacement therapy 3

Important Caveats

• Never delay treatment of suspected adrenal crisis for diagnostic procedures 1
• Adrenal crises requiring hospital treatment occur in approximately 6-8 per 100 patient-years among patients with adrenal insufficiency 1
• Mortality risk is significantly higher in patients with adrenal insufficiency (risk ratio 2.19 for men, 2.86 for women) 1
• In the only prospective study to date, the incidence of adrenal crisis was 8.3 per 100 replacement years, with two deaths during a 2-year follow-up 1