Treatment of Adrenal Crisis Following Steroid Use and Discontinuation
The immediate treatment for adrenal crisis requires prompt administration of intravenous hydrocortisone 100 mg bolus, followed by 100-300 mg daily as continuous infusion or divided doses every 6 hours, along with rapid fluid resuscitation using 3-4 L of isotonic saline. 1, 2
Initial Emergency Management
- Treatment must not be delayed for diagnostic procedures - draw blood for cortisol, ACTH, electrolytes, and tests for precipitating causes, but initiate treatment immediately 1, 2
- Administer hydrocortisone 100 mg IV bolus immediately to achieve both glucocorticoid and mineralocorticoid effects 1, 2
- Provide rapid IV fluid resuscitation with isotonic saline at an initial rate of approximately 1 L/hour 1, 2
- Monitor vital signs, particularly blood pressure and heart rate, frequently to assess response to treatment 2
- Identify and treat the precipitating cause (often infection, surgery, trauma, or abrupt steroid discontinuation) 1, 3
Continued Hospital Management
- Continue hydrocortisone 100-300 mg/day as either continuous infusion or divided IV/IM doses every 6 hours for the first 24-48 hours 1, 2
- Continue IV isotonic saline infusion at a slower rate for the next 24-48 hours, with frequent hemodynamic monitoring and electrolyte measurements to avoid fluid overload 1
- Consider admission to intensive care or high-dependency unit depending on the severity of the crisis 1
- Implement prophylaxis for gastric stress ulcers and consider low-dose heparin if appropriate 1
- Administer antibiotics if infection is suspected or confirmed 1
Transition to Maintenance Therapy
- Taper parenteral glucocorticoids over 1-3 days as clinical condition improves 1, 2
- Transition to oral maintenance therapy with appropriate dosing (typically hydrocortisone 15-20 mg daily in divided doses) 2
- Restart mineralocorticoid replacement with fludrocortisone when hydrocortisone dose falls below 50 mg/day for patients with primary adrenal insufficiency 1, 2
- Monitor electrolytes, particularly sodium and potassium, during the transition period 1, 2
Prevention of Future Adrenal Crises
- Identify and address the precipitating cause of the adrenal crisis (often abrupt steroid discontinuation) 1
- Provide comprehensive patient education on stress dosing during illness (typically 2-3 times maintenance dose) 1, 2, 4
- Prescribe an emergency injectable hydrocortisone kit and provide training on self-administration 2, 5
- Recommend a medical alert bracelet or identification card indicating steroid dependency 2, 5
- Emphasize the importance of never abruptly discontinuing steroid therapy and proper tapering schedules 6, 7
- Schedule regular follow-up to evaluate replacement therapy adequacy 1, 2
Common Pitfalls to Avoid
- Delaying treatment while waiting for diagnostic confirmation can be fatal 2, 5
- Inadequate fluid resuscitation alongside corticosteroid administration 2, 4
- Failing to identify and treat the precipitating cause of adrenal crisis 2, 3
- Tapering corticosteroids too quickly before clinical stabilization 2, 6
- Overlooking the need for mineralocorticoid replacement in primary adrenal insufficiency 1, 2
- Insufficient patient education about stress dosing and emergency management 4, 5
- Underestimating the risk of adrenal crisis following steroid discontinuation, even with inhaled corticosteroids at high doses 8
Recent evidence suggests that continuous intravenous hydrocortisone infusion may be superior to intermittent bolus administration for maintaining appropriate cortisol levels during major stress 9, though this approach may not be practical in all settings.