Initial Treatment of Suspected Adrenal Insufficiency
Administer hydrocortisone 100 mg IV immediately upon suspicion of adrenal insufficiency, without waiting for laboratory confirmation, followed by aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour. 1, 2
Emergency Management Protocol
Immediate Actions (Do Not Delay)
Give hydrocortisone 100 mg IV bolus as soon as adrenal crisis is suspected—this is the single most critical intervention and should never be delayed for diagnostic testing 1, 2, 3
Initiate rapid fluid resuscitation with 0.9% isotonic saline at 1 L/hour in the first hour to address severe dehydration and hypotension 1, 2, 3
Draw blood samples for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before hydrocortisone administration if immediately feasible, but never delay treatment waiting for results 1, 4
Why This Dose and Route
The 100 mg IV dose provides both glucocorticoid and mineralocorticoid effects by saturating 11β-hydroxysteroid dehydrogenase type 2, eliminating the need for separate mineralocorticoid administration in the acute phase 2
This is FDA-approved for primary or secondary adrenocortical insufficiency when oral therapy is not feasible 5
Alternative if Diagnosis Uncertain
- If you still need to perform ACTH stimulation testing and the diagnosis is not yet confirmed, use dexamethasone 4 mg IV instead, as it does not interfere with cortisol assays 4
Continuation Phase (After Initial Bolus)
Continue glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1
Continuous IV infusion of 200 mg hydrocortisone over 24 hours is superior to intermittent bolus administration for maintaining cortisol concentrations in the physiological range during major stress 6, 3
Investigate and treat the precipitating cause (infection is the most common trigger) 1, 3
Critical Pitfalls to Avoid
Never delay treatment for diagnostic confirmation—mortality increases with delayed intervention, and diagnosis can be established later even after treatment has commenced 1, 2, 3
Do not rely on hyperkalemia to confirm diagnosis—it is present in only 50% of cases, while hyponatremia occurs in 90% but its absence should not prevent treatment 1, 4
Do not wait for "classic" presentation—patients may have normal electrolytes in 10-20% of cases 4
High-Risk Scenarios Requiring Immediate Treatment
Any patient taking ≥20 mg/day prednisone or equivalent for at least 3 weeks who develops unexplained hypotension 4
Hypotension requiring high-dose vasopressors or multiple vasopressor agents that remains refractory to treatment 4
Unexplained collapse with hypotension and gastrointestinal symptoms (vomiting or diarrhea) 4
Transition to Maintenance (Once Stabilized)
Taper parenteral glucocorticoids over 1-3 days to oral therapy once the patient is stabilized and can tolerate oral medications 2
Transition to maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses 1, 2, 7
Add fludrocortisone 50-200 μg daily as a single morning dose for mineralocorticoid replacement in primary adrenal insufficiency once oral intake is established 1, 2, 7