What is the treatment for adrenal crisis symptoms?

Treatment of Adrenal Crisis

Immediately administer hydrocortisone 100 mg IV bolus without delaying for any diagnostic procedures, followed by aggressive fluid resuscitation with 0.9% saline 1 liter over the first hour. 1, 2, 3

Immediate Emergency Management (First Hour)

• Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this dose saturates mineralocorticoid receptors and provides both glucocorticoid and mineralocorticoid effects, eliminating the need for separate fludrocortisone during acute crisis. 1, 2, 3

• Start 0.9% isotonic saline at 1 liter over the first hour to address the profound volume depletion and hypotension that characterize adrenal crisis. 1, 2, 3

• Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before treatment begins, but never delay therapy waiting for results—treatment must not be postponed for diagnostic confirmation as mortality increases with delayed intervention. 1, 2

Ongoing Management (First 24-48 Hours)

• Continue hydrocortisone 100-300 mg per day, either as continuous IV infusion or as divided IV/IM boluses every 6 hours. 1, 2, 3

• Maintain slower isotonic saline infusion for 24-48 hours with total fluid administration of 3-4 liters, adjusting based on hemodynamic response and frequent monitoring to avoid fluid overload. 1, 2

• Monitor serum electrolytes frequently to guide fluid management—expect hyponatremia (present in ~90% of cases), hyperkalemia (in ~50%), and potentially hypoglycemia and increased creatinine. 1, 2

• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction. 1, 2

• Treat precipitating causes aggressively—gastrointestinal illness with vomiting/diarrhea is the most common trigger, followed by infections, surgical procedures without adequate steroid coverage, trauma, myocardial infarction, and severe allergic reactions. 1, 2, 4

• Provide gastric stress ulcer prophylaxis and consider low-dose heparin depending on severity of intercurrent illness. 1, 2

Critical Clinical Pitfalls to Avoid

• Do not add separate mineralocorticoid (fludrocortisone) during acute crisis—the high-dose hydrocortisone provides adequate mineralocorticoid activity through receptor saturation. 2

• Never postpone treatment to obtain diagnostic confirmation—even mild symptoms like upset stomach can rapidly progress to life-threatening crisis, especially since patients cannot absorb oral medications when they need them most. 2, 4, 5

• Do not be falsely reassured by absence of hyperkalemia—it is present in only half of cases, and hyponatremia, while very common (90%), may also be absent in some patients. 2

• Consider adrenal crisis in any patient with unexplained collapse, hypotension, vomiting, or diarrhea, especially with electrolyte abnormalities—the diagnosis is often missed due to nonspecific presentation. 2, 6

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness permits and the patient can tolerate oral medications. 1, 3

• Transition to maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses, with preference for short-acting hydrocortisone over longer-acting agents like prednisone. 7, 3

Prevention of Future Crises

• Provide comprehensive patient education on stress dosing—instruct patients to double or triple their glucocorticoid dose during minor illness and to use parenteral hydrocortisone during severe illness or inability to take oral medications. 1, 3, 5

• Ensure every patient has emergency supplies including injectable hydrocortisone for self-administration, though current education concepts are not sufficiently effective and improved strategies are needed. 1, 3, 4

• Recommend medical alert jewelry and emergency steroid card to trigger stress-dose corticosteroids by emergency medical personnel. 7, 1, 3

• Arrange early endocrinology consultation for ongoing management, education on emergency injectables, and planning before surgery or high-stress treatments. 7

• Review the precipitating cause and patient's understanding of stress dosing after each crisis, as failure to increase glucocorticoid doses during intercurrent illness remains a common cause despite patient education. 1, 2

Special Considerations

• In pediatric patients, administer initial normal saline fluid bolus of 10-20 ml/kg (maximum 1,000 ml) and consider stress-dose hydrocortisone specifically for vasopressor-resistant hypotension. 2

• In patients on immune checkpoint inhibitors who develop hypophysitis or adrenal insufficiency, be particularly vigilant when tapering high-dose corticosteroids used for other immune-related adverse events, as rapid tapering can precipitate crisis. 2

• Medications that accelerate cortisol clearance require glucocorticoid dose adjustments to prevent crisis. 2

• Never start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies, as this can trigger adrenal crisis. 7, 2