Management of Adrenal Insufficiency with Persistent Vomiting
For patients with adrenal insufficiency who develop persistent vomiting, immediately administer hydrocortisone 100 mg IV bolus and initiate aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour—treatment must never be delayed for diagnostic confirmation. 1, 2
Immediate Emergency Management
The inability to absorb oral glucocorticoids during vomiting represents a life-threatening emergency in patients with adrenal insufficiency, as even mild gastrointestinal upset can precipitate adrenal crisis when patients cannot take their medication when they need it most. 1
First-Line Interventions (Within Minutes)
Administer hydrocortisone 100 mg IV bolus immediately upon recognition of persistent vomiting in a patient with known adrenal insufficiency—this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect. 1, 2
Begin aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour, as dehydration and volume depletion are key pathophysiologic features of adrenal crisis. 1, 2
Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before treatment begins, but do not wait for results to initiate therapy. 1, 2
Ongoing Parenteral Glucocorticoid Therapy
Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion (or alternatively hydrocortisone 50 mg IV/IM every 6 hours) while the patient remains unable to tolerate oral medications. 3, 1, 2
Maintain IV fluid resuscitation with 3-4 liters total of isotonic saline or 5% dextrose in isotonic saline over 24 hours, adjusting based on hemodynamic response and frequent electrolyte monitoring. 1, 2
Do not add separate mineralocorticoid (fludrocortisone) during acute crisis management, as high-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity. 1, 4
Critical Clinical Pitfalls to Avoid
Never delay treatment waiting for diagnostic confirmation—mortality increases with delayed intervention, and treatment should begin immediately upon clinical suspicion. 1, 2, 4
Gastrointestinal illness with vomiting/diarrhea is the most common trigger for adrenal crisis in patients with known adrenal insufficiency, accounting for the majority of preventable deaths. 1, 5
Inadequate fluid resuscitation alongside corticosteroid administration is a common error—both interventions are equally critical and must be implemented simultaneously. 4
Transition Back to Oral Therapy
Resume oral hydrocortisone only when the patient can reliably tolerate oral medications and the precipitating illness (vomiting) has resolved. 3, 1
Double the usual oral hydrocortisone dose for 48 hours after resuming oral intake following uncomplicated recovery, or continue doubled doses for up to a week if the illness was severe. 3, 1
Restart fludrocortisone when the hydrocortisone dose falls below 50 mg per day, as lower doses no longer provide adequate mineralocorticoid effect in primary adrenal insufficiency. 1, 4
Taper parenteral glucocorticoids over 1-3 days once the patient demonstrates stable oral intake and clinical improvement. 1, 2
Prevention of Future Crises
The most important intervention after acute management is comprehensive patient education, as inadequate adjustment of glucocorticoid dosage during intercurrent illness is the leading cause of preventable death in patients with adrenal insufficiency. 1, 5
Teach "sick day rules": double or triple oral glucocorticoid doses during minor illness with nausea, vomiting, fever, or diarrhea. 1, 2, 6
Prescribe emergency injectable hydrocortisone 100 mg IM and train patients/families on self-injection technique for use when oral medications cannot be absorbed. 1, 2, 6
Provide medical alert jewelry and emergency steroid card to trigger stress-dose corticosteroids by emergency medical personnel. 1, 4
Arrange 24-hour access to endocrinology consultation so patients can contact an on-call endocrinologist during acute illness. 5
Monitoring During Acute Management
Monitor vital signs frequently, particularly blood pressure (including orthostatic measurements) and heart rate, as orthostatic hypotension appears before supine hypotension and represents an early warning sign. 1, 4
Check electrolytes frequently to guide fluid management—hyponatremia is present in ~90% of cases and hyperkalemia in ~50%, though absence does not exclude crisis. 1, 2
Monitor blood glucose closely, especially in pediatric patients who are more vulnerable to hypoglycemia. 1
Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction. 1, 2