Adrenal crisis, acute (Adrenal Insufficiency)

Adrenal Crisis, Acute (Adrenal Insufficiency) – Treatment Options

Introduction
Acute adrenal crisis is a life-threatening emergency that results from insufficient cortisol production, often in the setting of known or undiagnosed adrenal insufficiency. It may be triggered by infection, trauma, surgery, or abrupt discontinuation of corticosteroid therapy. The condition is characterized by hypotension, hypovolemia, electrolyte imbalances, and hypoglycemia. Immediate recognition and prompt treatment are critical to prevent shock, organ failure, and death.

1. Immediate Intravenous Hydrocortisone

• Hydrocortisone sodium succinate is the mainstay of therapy due to its combined glucocorticoid and mineralocorticoid effects.

• Initial dose: 100 mg IV bolus, followed by 200 mg over 24 hours (either continuous infusion or 50 mg IV every 6 hours).

• Rapid administration restores cortisol levels essential for vascular tone, glucose metabolism, and stress response.

2. Intravenous Fluid Replacement

• 0.9% Sodium Chloride (Normal Saline): Administer 1 liter rapidly in the first hour to correct hypovolemia and hypotension.

• Subsequent infusions are guided by blood pressure, urine output, and electrolyte levels.

• Dextrose (5–10% in normal saline): Added if hypoglycemia is present or suspected, providing rapid glucose replenishment.

3. Correction of Hypoglycemia

• If blood glucose is critically low, administer IV 50% dextrose bolus, followed by continuous glucose-containing fluids as needed.

• Regular blood glucose monitoring is essential during the acute phase.

4. Electrolyte Monitoring and Correction

• Hyponatremia and hyperkalemia are hallmark disturbances in adrenal crisis.

• Frequent electrolyte checks guide management, with targeted correction measures as supportive therapy alongside hydrocortisone.

5. Transition to Oral Therapy

• Once hemodynamically stable and able to tolerate oral intake, switch from IV to oral steroids:

  • Hydrocortisone 15–25 mg/day in divided doses.

• Fludrocortisone (0.05–0.2 mg/day) may be introduced to ensure adequate mineralocorticoid replacement when IV therapy is tapered.

6. Identification and Treatment of Underlying Cause

• Common precipitants include infection, surgery, trauma, or omission of corticosteroid therapy.

• Empiric broad-spectrum antibiotics are considered in cases where sepsis is suspected.

• The patient’s baseline glucocorticoid regimen should be reviewed and optimized for long-term maintenance.

7. Patient Education and Prevention

• Patients must be counseled on prevention strategies, including carrying a steroid emergency card and wearing medical alert identification.

• Provision of emergency hydrocortisone injection kits (100 mg IM/IV) is recommended.

• Education on stress dosing during illness, surgery, or trauma helps reduce recurrence risk.