What is the treatment for adrenal insufficiency due to adrenal infarct or hemorrhage?

Treatment of Adrenal Insufficiency Due to Adrenal Infarct or Hemorrhage

Immediate treatment of adrenal insufficiency due to adrenal infarct or hemorrhage requires prompt administration of hydrocortisone 100 mg IV bolus followed by fluid resuscitation with 0.9% saline, without delaying for diagnostic procedures. 1

Emergency Management

Initial Resuscitation

• Administer hydrocortisone 100 mg IV immediately upon suspicion of adrenal crisis 1
• Begin fluid resuscitation with 0.9% saline, 1 L over the first hour, followed by 3-4 L over 24-48 hours 1
• Continue glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1, 2
• Obtain blood samples for cortisol, ACTH, electrolytes, creatinine, urea, and glucose (but do not delay treatment) 2, 1
• Investigate and treat the precipitating cause (infection, bleeding, etc.) 2

Stabilization Phase

• Monitor vital signs, electrolytes, and glucose levels frequently 1
• Consider ICU/high-dependency unit admission for hemodynamic monitoring 1
• Taper parenteral glucocorticoids over 1-3 days once the patient is stabilized 1
• Transition to oral maintenance therapy when the patient can tolerate oral medications 2

Maintenance Therapy

Glucocorticoid Replacement

• Hydrocortisone 15-25 mg daily in divided doses (typically 10 mg on awakening, 5 mg at noon, 2.5-5 mg in late afternoon) 2
• First dose immediately after waking, and the last dose not less than 6 hours before bedtime 2
• Use the lowest dose compatible with health and well-being 2, 3
• Alternative regimens include prednisolone 4-5 mg daily (3 mg on awakening and 1-2 mg at 14:00) for patients with marked fluctuations in energy 2

Mineralocorticoid Replacement

• Fludrocortisone 50-200 μg daily as a single dose upon awakening 2
• Higher doses (up to 500 μg daily) may be needed in children, younger adults, or during pregnancy 2
• Continue mineralocorticoid even if essential hypertension develops (reduce dose but do not stop) 2
• Advise patients to consume salt and salty foods without restriction 2

Special Situations

Surgery and Invasive Procedures

• Major surgery: 100 mg hydrocortisone IM just before anesthesia, then 100 mg IM every 6 hours until able to eat and drink 2
• Minor surgery: 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 2
• Dental procedures: Extra morning dose 1 hour prior to procedure, then double oral dose for 24 hours 2

Acute Illness

• Minor illness with fever: Double or triple oral glucocorticoid dose 1
• Vomiting or severe illness: Administer parenteral hydrocortisone 100 mg IM and seek immediate medical attention 1, 2

Prevention of Future Crises

• Educate patients on stress dosing during illness or physical stress 1
• Provide emergency supplies of injectable hydrocortisone 1
• Recommend medical alert identification (bracelet/card) 1
• Schedule regular follow-up at least annually to assess health, weight, blood pressure, and electrolytes 2
• Monitor for development of other autoimmune disorders, particularly hypothyroidism 2

Common Pitfalls and Caveats

• Delaying treatment while waiting for diagnostic confirmation can be fatal - treat first, diagnose later 1, 4
• Inadequate fluid resuscitation can lead to persistent hypotension despite glucocorticoid administration 1
• Medications that interact with glucocorticoids (e.g., anti-epileptics, barbiturates, antituberculosis drugs) may require dose adjustments 2
• Avoid medications that interact with fludrocortisone (diuretics, acetazolamide, carbenoxolone, NSAIDs) 2
• Avoid liquorice and grapefruit juice as they potentiate the mineralocorticoid effect of hydrocortisone 2
• Patients on corticosteroids for other conditions may have iatrogenic secondary adrenal insufficiency with low morning cortisol and ACTH 2

By following this treatment algorithm for adrenal insufficiency due to adrenal infarct or hemorrhage, clinicians can effectively manage both the acute crisis and long-term replacement therapy to optimize patient outcomes.