A patient with primary adrenal insufficiency on maintenance hydrocortisone (10 mg morning, 5 mg midday, 5 mg afternoon) and fludrocortisone develops an acute gout flare; how should glucocorticoid dosing be adjusted and what gout therapy is recommended to prevent adrenal crisis?

Adrenal Crisis Prevention During Acute Gout Flare in Primary Adrenal Insufficiency

For a patient with primary adrenal insufficiency experiencing an acute gout flare, immediately increase hydrocortisone to stress-dose levels (double to triple the maintenance dose, typically 50-75 mg daily in divided doses) and use systemic glucocorticoids as first-line gout therapy—this approach simultaneously treats the gout flare and prevents adrenal crisis. 1, 2

Glucocorticoid Stress-Dosing Protocol

The acute gout flare itself is a physiologic stressor requiring increased glucocorticoid coverage to prevent adrenal crisis. 1

Immediate Dose Adjustment

• Double or triple the patient's maintenance hydrocortisone dose during the acute gout flare—for this patient on 20 mg daily total, increase to 40-60 mg daily in divided doses (e.g., 20 mg morning, 10 mg midday, 10 mg afternoon). 1, 3
• Continue stress-dosing until the gout flare completely resolves, typically 5-7 days, then taper back to maintenance dosing over 1-2 days. 1
• Never delay stress-dose adjustment—the frequency of acute adrenal crises is 6-8 per 100 patient-years, and inadequate dose adjustment during illness is a leading precipitant. 1

Mineralocorticoid Management

• Continue fludrocortisone at the usual maintenance dose (no adjustment needed during stress-dosing with hydrocortisone <100 mg/day). 1
• If hydrocortisone doses exceed 50 mg daily, the glucocorticoid provides sufficient mineralocorticoid effect through saturation of 11β-HSD type 2 receptors. 1

Gout Flare Treatment Strategy

Systemic glucocorticoids serve dual purposes: treating the gout flare AND providing necessary stress-dose coverage for adrenal insufficiency. 1, 2

First-Line Therapy: Glucocorticoids

• Prednisolone 35 mg daily for 5 days is highly effective for acute gout and has been specifically validated in patients with adrenal insufficiency. 2
• Alternatively, use the increased hydrocortisone stress-dose itself (50-75 mg daily) as anti-inflammatory therapy—this is equivalent to approximately 12.5-18.75 mg prednisolone and may suffice for mild-moderate gout flares. 1, 4
• Glucocorticoids are as effective as NSAIDs for gout flares and avoid NSAID-related risks (renal impairment, fluid retention, hypertension). 1, 2

Alternative Agents (If Glucocorticoids Insufficient)

• Colchicine can be used cautiously: FDA-approved dosing is 1.2 mg immediately followed by 0.6 mg one hour later (total 1.8 mg). 1, 2
• Critical pitfall: Colchicine's gastrointestinal side effects (nausea, vomiting, diarrhea) can mimic early adrenal crisis—if these symptoms develop, immediately increase hydrocortisone to 100 mg IV and seek emergency care. 1, 2
• NSAIDs should generally be avoided in patients with adrenal insufficiency due to increased risk of renal complications, fluid/electrolyte disturbances, and potential to mask adrenal crisis symptoms. 2

Adjunctive Therapy

• Topical ice application to the affected joint is conditionally recommended as adjuvant treatment. 1

Monitoring for Adrenal Crisis

Remain vigilant for signs of impending adrenal crisis throughout the gout flare, as the inflammatory stress can precipitate decompensation despite dose adjustment. 1

Warning Signs Requiring Emergency Treatment

• Severe nausea, vomiting, or diarrhea (especially if unable to retain oral medications). 1
• Hypotension, orthostatic symptoms, or confusion/altered mental status. 1
• Severe abdominal pain with peritoneal signs. 1
• Inability to increase oral hydrocortisone due to gastrointestinal symptoms. 1

Emergency Protocol

• If any crisis features develop: immediately administer 100 mg hydrocortisone IV bolus (or IM if IV access unavailable) and infuse 0.9% saline at 1 L/hour. 1, 3
• Never delay emergency treatment for diagnostic procedures—mortality is high if adrenal crisis is untreated. 1, 3
• The patient should have a pre-filled hydrocortisone 100 mg IM injection kit at home with training in self-administration. 1, 3

Long-Term Gout Management

Defer initiation of urate-lowering therapy until after the acute flare has completely resolved. 2

After Flare Resolution

• For patients with ≥2 gout flares per year, initiate urate-lowering therapy with allopurinol starting at low dose (50-100 mg daily) and titrate gradually to achieve serum urate <6 mg/dL. 1, 2
• No special precautions or dose adjustments of allopurinol or other urate-lowering agents are required in patients with stable adrenal insufficiency. 2
• Continue prophylactic anti-inflammatory therapy (low-dose colchicine 0.6 mg daily or low-dose prednisone 5 mg daily) during allopurinol titration to prevent flares. 1

Patient Education Reinforcement

Use this acute event to reinforce stress-dosing education and crisis prevention strategies. 1

• Ensure the patient understands when and how to double/triple hydrocortisone doses during illness, fever, or physical stress. 1, 3
• Confirm the patient wears a medical alert bracelet indicating adrenal insufficiency. 1, 3
• Review warning signs of adrenal crisis and when to use emergency injectable hydrocortisone. 1, 3
• Emphasize that any intercurrent illness—including gout flares—requires immediate stress-dose adjustment to prevent crisis. 1