Hydrocortisone Prescription for Adrenal Crisis
For acute adrenal crisis, immediately administer hydrocortisone 100 mg IV bolus, followed by continuous IV infusion of 200 mg over 24 hours, along with rapid IV saline resuscitation (1 liter of 0.9% saline over the first hour). 1, 2
Immediate Emergency Treatment
- Do not delay treatment for diagnostic testing—draw blood for cortisol and ACTH levels, then start therapy immediately 1
- Administer hydrocortisone 100 mg IV push over 30 seconds to 10 minutes 3
- This initial bolus saturates 11β-HSD type 2 enzymes to provide mineralocorticoid effect, which is critical since high-dose hydrocortisone is needed to achieve mineralocorticoid activity 1
- Simultaneously begin aggressive fluid resuscitation with 0.9% normal saline—infuse 1 liter over the first hour 1, 2
Continuous Maintenance Phase
- Immediately after the bolus, initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours (approximately 8.3 mg/hour) 1, 2, 4
- This continuous infusion is superior to intermittent bolus dosing because it maintains cortisol concentrations persistently in the range observed during major physiological stress 4
- Alternative regimen (if continuous infusion is not feasible): hydrocortisone 50 mg IV or IM every 6 hours 1
- Continue IV hydrocortisone at 200 mg/24 hours for 24-48 hours or until the patient is stable and able to tolerate oral intake 1
Transition to Oral Therapy
- Once the patient can tolerate oral intake and the precipitating illness is controlled, transition to oral hydrocortisone at double the patient's usual maintenance dose (typically 30-50 mg/day in divided doses) for 48 hours 1
- If recovery is complicated or the patient had major stress, continue doubled oral doses for up to one week before tapering 1
- Standard maintenance dosing is 15-25 mg/day in divided doses (typically 10 mg upon waking, 5 mg at lunch, 5 mg in late afternoon) 5
Critical Supportive Measures
- Continue slower IV saline infusion for 24-48 hours after the initial liter to maintain adequate hydration 1
- Identify and treat the precipitating cause (infection is the most common trigger, accounting for the majority of adrenal crises) 1, 2
- Monitor serum sodium, potassium, glucose, and creatinine—expect hyponatremia, hyperkalemia, and prerenal azotemia 1
- For patients with primary adrenal insufficiency, add fludrocortisone 0.05-0.2 mg daily once oral intake resumes, as they require mineralocorticoid replacement 1, 5
Common Pitfalls to Avoid
- Never use dexamethasone as the primary agent in adrenal crisis—it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult 6
- Do not abruptly stop stress-dose steroids—always taper gradually over 48 hours to one week depending on clinical recovery 1
- Recognize that adrenal crisis occurs at a rate of 6-8 episodes per 100 patient-years in those with known adrenal insufficiency, with a mortality rate of 0.5 per 100 patient-years if not treated promptly 2, 5
- Patients may present with nonspecific symptoms (profound malaise, nausea, vomiting, abdominal pain, confusion, or altered mental status) that can mimic other acute conditions—maintain high clinical suspicion 1, 2
Prevention and Patient Education
- All patients with adrenal insufficiency should carry an emergency card and be provided with an emergency kit containing injectable hydrocortisone 100 mg for self-administration 2
- Educate patients to double or triple their oral hydrocortisone dose during febrile illness, gastroenteritis, or other physiological stress to prevent progression to adrenal crisis 2, 5
- Prescribe injectable hydrocortisone 100 mg IM for home use in case of vomiting or inability to take oral medication 5