Can steroids be administered to a patient suspected of having adrenal insufficiency?

Administration of Steroids in Suspected Adrenal Insufficiency

Yes, steroids should be administered immediately to patients with suspected adrenal insufficiency, as delayed treatment can lead to adrenal crisis, which is potentially fatal. 1

Initial Assessment and Management

• For patients with suspected adrenal insufficiency, immediate administration of hydrocortisone 100 mg as an intravenous bolus is recommended, followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
• Fluid resuscitation with 3-4 L of isotonic saline or 5% dextrose in isotonic saline should be initiated simultaneously, with an initial infusion rate of approximately 1 L/hour 1
• Clinical diagnosis should take precedence over laboratory confirmation when adrenal insufficiency is suspected - do not delay treatment while waiting for test results 1
• For severe symptoms (hypotension, altered mental status), hospitalization or emergency department referral is necessary for IV stress-dose steroids and fluid management 1

Severity-Based Approach

Mild to Moderate Symptoms

• For ambulatory patients with moderate symptoms but stable vital signs, consider oral hydrocortisone at 2-3 times maintenance dose (typically 30-75 mg/day in divided doses) 1, 2
• If symptoms are concerning but not immediately life-threatening, oral pulse dose therapy with prednisone 1 mg/kg/day may be appropriate 1
• Continue close monitoring for clinical deterioration 1

Severe Symptoms/Adrenal Crisis

• Immediate IV hydrocortisone 100 mg bolus followed by 50-100 mg every 6-8 hours 1
• Aggressive fluid resuscitation with isotonic saline to correct hypotension and electrolyte abnormalities 1
• Monitor hemodynamic parameters and electrolytes frequently to avoid fluid overload 1
• Consider ICU admission for patients with severe presentations 1

Important Considerations

• When administering steroids to patients with suspected adrenal insufficiency who also have other endocrine deficiencies, always start corticosteroids first, as other hormone replacements can accelerate cortisol clearance and precipitate adrenal crisis 1
• ACTH stimulation testing can give false-negative results early in the course of adrenal insufficiency, especially in secondary adrenal insufficiency; in cases of clinical uncertainty, it is safer to provide replacement therapy and test for ongoing need later 1
• Mineralocorticoid replacement with fludrocortisone should be considered when the hydrocortisone dose falls below 50 mg/day in patients with primary adrenal insufficiency 1, 3
• All patients started on steroids for suspected adrenal insufficiency should receive education on stress dosing for illness, emergency steroid injection, and should be advised to obtain a medical alert bracelet 1

Tapering and Maintenance

• Once the patient is stabilized, taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy if the precipitating illness permits 1
• Maintenance therapy typically consists of hydrocortisone 15-25 mg daily in divided doses (typically higher dose in morning) 4, 5
• For primary adrenal insufficiency, add fludrocortisone 0.05-0.2 mg daily for mineralocorticoid replacement 3, 4

Cautions and Pitfalls

• Do not withhold steroids in suspected adrenal insufficiency due to concerns about confirming the diagnosis - adrenal crisis has a high mortality rate if untreated 6, 7
• Avoid waiting for classic signs of adrenal crisis (volume-resistant hypotension) as these may be late or agonal events; earlier symptoms include malaise, somnolence, and cognitive dysfunction 1
• Be vigilant for adrenal insufficiency in patients on chronic steroid therapy who are undergoing surgery or experiencing acute illness 1
• Monitor for potential adverse effects of high-dose steroids, but recognize that in true adrenal insufficiency, these risks are outweighed by the benefits of replacement 8, 9