Management of Adrenal Insufficiency with Nausea, Vomiting, and Diarrhea
A patient with adrenal insufficiency presenting with nausea, vomiting, and diarrhea requires immediate parenteral hydrocortisone 100 mg IV bolus and aggressive fluid resuscitation, as this represents a potential adrenal crisis—gastrointestinal illness is the most common precipitating factor for adrenal crisis and oral medications cannot be absorbed when patients need them most. 1, 2
Immediate Recognition and Action
Treat first, diagnose later. Treatment must never be delayed for diagnostic procedures when adrenal crisis is suspected. 3, 1, 2
Why This is an Emergency
- Gastrointestinal illness with vomiting/diarrhea is the single most common trigger for adrenal crisis in patients with known adrenal insufficiency. 1, 2
- Even mild upset stomach may precipitate crisis because patients cannot absorb their oral glucocorticoid replacement when they need it most. 2
- Mortality rate is 0.5 per 100 patient-years if not managed appropriately. 4
Initial Emergency Protocol
Step 1: Immediate hydrocortisone administration
- Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—do not wait for laboratory confirmation. 1, 2, 5
- This high dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect, eliminating the need for separate fludrocortisone during acute crisis. 2
- If IV access cannot be rapidly established, give hydrocortisone 100 mg intramuscularly as an acceptable backup. 2
Step 2: Aggressive fluid resuscitation
- Start 0.9% isotonic saline at 1 liter over the first hour. 1, 2, 5
- Continue with 3-4 liters total over 24-48 hours with frequent hemodynamic monitoring. 1, 2
- Volume depletion and dehydration are key pathophysiologic features requiring aggressive correction. 2
Step 3: Draw diagnostic blood samples before treatment (but do not delay therapy)
- Obtain serum cortisol, ACTH, electrolytes, creatinine, urea, and glucose. 1, 2
- These confirm diagnosis retrospectively but should never delay treatment. 3, 1
Ongoing Management During Crisis
Continuous Glucocorticoid Administration
Maintain hydrocortisone 200 mg per 24 hours as continuous IV infusion while the patient remains unable to tolerate oral medications. 2, 5
Alternative dosing regimen:
- Hydrocortisone 50 mg IV or IM every 6 hours (total 200 mg/day). 1, 2, 5
- Both approaches provide equivalent coverage; choose based on IV access reliability and nursing capabilities. 2
Critical Monitoring Parameters
- Monitor serum electrolytes frequently to guide fluid management and avoid complications. 2
- Check blood glucose hourly, especially in pediatric patients who are more vulnerable to hypoglycemia. 2
- Assess blood pressure in both supine and standing positions—orthostatic hypotension occurs before supine hypotension and represents an earlier warning sign. 2
- Do not attribute persistent fever solely to infection; it may be due to adrenal insufficiency itself, and steroid supplementation should not be reduced while the patient is febrile. 2
Common Pitfall to Avoid
Do not add separate mineralocorticoid (fludrocortisone) during acute crisis management. High-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity. 2 Only restart fludrocortisone when hydrocortisone dose falls below 50 mg per day during tapering. 2
Transition Back to Oral Therapy
When to Resume Oral Medications
Resume oral hydrocortisone only when:
- The patient can reliably tolerate oral medications without vomiting. 2
- The precipitating gastrointestinal illness has resolved. 2
Tapering Protocol
- Taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy once stabilized. 1, 5
- Double the usual oral hydrocortisone dose for 48 hours after resuming oral intake following uncomplicated recovery. 2
- Return to standard maintenance dose (15-25 mg daily in 2-3 divided doses) once stability is achieved. 3, 5
Supportive Care Considerations
- Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or altered mental status. 1
- Provide gastric stress ulcer prophylaxis during high-dose glucocorticoid therapy. 3, 1
- Consider low-dose heparin prophylaxis depending on severity of illness and immobility. 1
- Treat any precipitating infections with appropriate antimicrobial therapy. 1, 4
Prevention of Future Episodes
Patient Education Essentials
All patients with adrenal insufficiency must be educated on "sick day rules" to prevent future crises. 3
Specific instructions:
- Double or triple oral glucocorticoid dose during minor illness with gastrointestinal symptoms. 2, 5
- Use parenteral hydrocortisone immediately if vomiting prevents oral medication absorption. 2, 5, 6
- Return to hospital immediately if feeling unwell or developing nausea/vomiting despite increased oral doses. 3
Emergency Supplies
Ensure every patient has:
- Injectable hydrocortisone emergency kit (100 mg for self/family administration). 3, 5
- Training for patient and family members on intramuscular injection technique. 3, 6
- Medical alert jewelry and steroid emergency card to trigger appropriate treatment by emergency personnel. 3, 5, 7
Common Causes of Recurrent Crises
Investigate these factors in patients with repeated episodes:
- Chronic under-replacement with fludrocortisone combined with low salt consumption. 2
- Poor compliance with mineralocorticoid therapy. 2
- Inadequate patient education on sick day rules despite prior teaching. 3, 2
- Underlying psychiatric disorders affecting medication adherence. 2
Special Clinical Scenarios
Pediatric Considerations
- Initial fluid bolus: 10-20 mL/kg (maximum 1,000 mL) normal saline. 2
- Hydrocortisone dosing: 2 mg/kg IV bolus, then 2 mg/kg every 4 hours. 3
- More frequent blood glucose monitoring is essential as children are more prone to hypoglycemia. 3, 2