What are the causes of adrenal crisis (Addisonian crisis)?

From the Guidelines

Adrenal crisis is most commonly caused by insufficient glucocorticoid medication during physiological stress, such as surgery, infections, or trauma, and can be triggered by various factors including abrupt withdrawal of long-term corticosteroid therapy, primary or secondary adrenal insufficiency, and certain medications. The causes of adrenal crisis can be multifaceted, involving both intrinsic and extrinsic factors that disrupt the body's normal cortisol production or increase its demand. According to 1, the incidence of adrenal crisis in patients with primary and secondary adrenal insufficiency is significant, with around 8.3 cases per 100 replacement years, highlighting the need for vigilant management and patient education.

Key Triggers and Causes

• Physiological stressors such as severe infections, trauma, surgery, vomiting, diarrhea, or extreme emotional distress can trigger adrenal crisis by increasing the body's demand for cortisol.
• Abrupt withdrawal of long-term corticosteroid therapy is a well-documented cause, as it suppresses the body's natural cortisol production.
• Primary adrenal insufficiency (Addison's disease), often due to autoimmune destruction of the adrenal glands, and secondary adrenal insufficiency resulting from pituitary gland disorders, are significant causes.
• Certain medications like ketoconazole, etomidate, and some anticonvulsants can inhibit cortisol synthesis or metabolism, potentially leading to adrenal crisis.
• Patients with known adrenal insufficiency are at heightened risk if they fail to adjust their glucocorticoid doses during illness or miss their regular medication, as emphasized in 1 and 1.

Management and Prevention

Prompt recognition and treatment with intravenous hydrocortisone, fluid resuscitation, and addressing the underlying trigger are essential to prevent potentially fatal outcomes. Education on "Sick Day Rules" and the importance of doubling the dose of steroids during periods of physiological stress, as well as the use of hydrocortisone self-administration kits in emergency situations, are crucial for patients with adrenal insufficiency, as highlighted in 1. Collaboration with the patient's endocrinologist and ensuring that the patient has priority in medical care, especially during scheduled surgery or postoperative care, is advisable, particularly for those with multiple risk factors.

Conclusion is not allowed, so the answer will be ended here.

From the Research

Causes of Adrenal Crisis

The causes of adrenal crisis can be attributed to various factors, including:

• Infection, often gastrointestinal 2, 3
• Fever 3
• Trauma 3
• Acute psychological or physical stress 3
• Gastrointestinal illness, which is the most common precipitant for an adrenal crisis 2
• Failure to increase glucocorticoid doses or switch to parenteral injections in patients with known adrenal insufficiency 2
• Delayed diagnosis and treatment of adrenal insufficiency 4, 5
• Non-adherence to "sick day rules" in patients with adrenal insufficiency 2

Triggers of Adrenal Crisis

Adrenal crisis can be triggered by various events, including:

• Infections 2, 3
• Trauma 3
• Surgery 3
• Acute medical illnesses 3
• Psychological stress 3
• Physical stress 3
• Gastrointestinal illness 2

Underlying Conditions

Adrenal crisis can occur in patients with underlying conditions, such as:

• Adrenal insufficiency 4, 2, 3
• Addison's disease 5
• Primary adrenal insufficiency 5
• Secondary adrenal insufficiency 4