eMedicine Specialties > Endocrinology > Adrenal Gland
Adrenal Crisis: Treatment & Medication
Updated: Aug 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Administration of glucocorticoids in supraphysiologic or stress doses is the only definitive therapy.5,6
- Dexamethasone does not interfere with serum cortisol assay and, thus, may be the initial drug of choice. However, because dexamethasone has little mineralocorticoid activity, fluid and electrolyte replacement are essential.
- A short ACTH stimulation test may be performed during resuscitation. Once complete, hydrocortisone 100 mg IV every 6 hours is the preferred treatment to provide mineralocorticoid support.
- Delaying glucocorticoid replacement therapy while awaiting the results of the ACTH stimulation test is inappropriate and dangerous.
- In addition to corticosteroid replacement, aggressive fluid replacement with 5% or 10% intravenous dextrose and saline solutions and treatment of hyperkalemia is mandatory. Fludrocortisone, a mineralocorticoid, may also be given.
- A thorough search for a precipitating cause and administration of empiric antibiotics is indicated. Reversal of coagulopathy should be attempted with fresh frozen plasma.
- Pressors (eg, dopamine, norepinephrine) may be necessary to combat hypotension.
Consultations
- Endocrinologist
- Infectious disease specialist
- Critical care physician
- Cardiologist
- Surgeon
- Other consultations as clinically indicated
Medication
Corticosteroids are the mainstays of treatment. Other medications, such as pressors (eg, dopamine, norepinephrine) or antibiotics, are administered as clinically indicated.
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Dexamethasone (Decadron, Baldex, Dexone)
Used as empiric treatment of shock in suspected adrenal crisis or insufficiency until serum cortisol levels are drawn.
Adult
4-8 mg IV, followed by 16-24 mg/d as IV injection q4-6h or as continuous infusion
Pediatric
Not established
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use; may prolong coma in cerebral malaria
Hydrocortisone (Hydrocortone, Hydrocort)
DOC because of mineralocorticoid activity and glucocorticoid effects.
Adult
Septic shock: 50-100 mg IV q6h for 7 d, then discontinue or reduce to 50 mg IV q6h for 4 doses then taper by one half qd until discontinued or until prior maintenance dose
Major surgical stress (CABG, esophagogastrectomy): Following usual am dose, give 100 mg IV before induction, 50 mg IV q8h for 24 h, then taper by one half qd to maintenance
Moderate surgical stress (extremity vascular bypass, total joint replacement): Following usual am dose, give 50 mg IV before induction, 25 mg IV q8h for 24 hours, then taper by one half qd to maintenance
Pediatric
<12 years: 1-2 mg/kg IV bolus; follow with 25-150 mg/d divided q6-8h
>12 years: 1-2 mg/kg IV bolus; follow with 150-250 mg/d divided q6-8h
Corticosteroid clearance may decrease with estrogens
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes mellitus, and myasthenia gravis
Cortisone acetate (Cortone)
Oral DOC for patients with adrenocortical insufficiency.
Use in patients undergoing moderate stress surgery (eg, vascular bypass, total joint replacement) who can take PO postoperatively.
Adult
Following intraoperative dose of hydrocortisone 50 mg IV, give 37.5 mg PO q12h for 2 d (as 25 mg PO qam and 12.5 mg PO qpm until stabilized)
Pediatric
Not established
Estrogen coadministration may increase corticosteroid levels; cortisone may increase digitalis toxicity secondary to hypokalemia; phenytoin, phenobarbital, rifampin, and ephedrine increase corticosteroid clearance; may inhibit response to coumarin anticoagulants; exacerbation of hypokalemia with potassium-depleting diuretics may occur
Documented hypersensitivity; viral, fungal, or tubercular skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, diabetes mellitus, and myasthenia gravis; may exacerbate existing emotional instability; may mask signs of GI peritonitis and sepsis; may impair growth and development in children; caution in peptic ulcer disease; caution in infections
Fludrocortisone (Florinef)
Acts on renal distal tubules to enhance reabsorption of sodium. Increases urinary excretion of both potassium and hydrogen ions. The consequence of these 3 primary effects, together with similar actions on cation transport in other tissues, appears to account for the spectrum of physiological activities characteristic of mineralocorticoids. Used in adrenal insufficiency. Produces marked sodium retention and increased urinary potassium excretion.
Adult
0.1-0.2 mg PO qd
Pediatric
0.05-0.1 mg PO qd
Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects of fludrocortisone; decreases salicylate levels
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Taper dose gradually when therapy is discontinued; caution in Addison disease, potassium loss, and sodium and fluid retention
Methylprednisolone (Medrol, Solu-Medrol, Depo-Medrol)
Usually third-line DOC for adrenal crisis because of lack of mineralocorticoid activity.
Consider use in patients with fluid overload, edema, or hypokalemia.
Adult
4 mg IV equals 20 mg IV hydrocortisone
10-20 mg IV q6-8h equals 50-100 mg IV hydrocortisone q6-8h
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics; grapefruit juice increases prednisolone concentrations; methylprednisolone and cyclosporine mutually inhibit one another, resulting in increased plasma levels of each drug
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use; Depo-Medrol contains benzyl alcohol, which is potentially toxic when administered locally to neural tissue; administration of Depo-Medrol by other than indicated routes, including the epidural route, has been associated with reports of serious medical events including arachnoiditis, meningitis, paraparesis/paraplegia, sensory disturbances, bowel/bladder dysfunction, seizures, visual impairment (including blindness and ocular and periocular inflammation), and residue or slough at injection site
Vasopressors
These agents are potent vasoconstrictors, inotropes and chronotropes. They should be used with caution in conjunction with corticosteroids and intravenous fluid support.
Norepinephrine (Levophed)
For protracted hypotension following adequate fluid-volume replacement. Stimulates beta1- and alpha-adrenergic receptors, which in turn, increases cardiac muscle contractility and heart rate, as well as vasoconstriction. As a result, systemic blood pressure and coronary blood flow increase. After obtaining a response, the rate of flow should be adjusted and maintained at a low-normal blood pressure, such as 80-100 mm Hg systolic, sufficient to perfuse vital organs.
Adult
4-12 mcg/min IV infusion; titrate to desired perfusion status
Pediatric
0.1 mcg/kg/min IV; titrate to desired perfusion status
Enhances pressor response of norepinephrine by blocking reflex bradycardia; MAOIs, TCAs, antihistamines, guanethidine, ergot alkaloids, and methyldopa increase effects
Documented hypersensitivity; peripheral or mesenteric vascular thrombosis (ischemia may be increased and the area of the infarct extended)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Correct blood volume depletion, if possible, before administering norepinephrine therapy; extravasation may cause severe tissue necrosis and, thus, should be administered into a large vein; caution in occlusive vascular disease; extravasation can cause tissue necrosis
Dopamine (Intropin)
Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on the dose.
Adult
0.5-20 mcg/kg/min IV infusion; titrate to desired perfusion status
Pediatric
Administer as in adults
Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects of dopamine
Documented hypersensitivity; pheochromocytoma; ventricular fibrillation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor urine flow, cardiac output, pulmonary wedge pressure, and blood pressure closely during the infusion; prior to infusion, correct hypovolemia with either whole blood or plasma because pressure may be helpful in detecting and treating hypovolemia; extravasation can cause tissue necrosis
More on Adrenal Crisis |
| Overview: Adrenal Crisis |
| Differential Diagnoses & Workup: Adrenal Crisis |
 Treatment & Medication: Adrenal Crisis |
| Follow-up: Adrenal Crisis |
| Multimedia: Adrenal Crisis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Further Reading
Related eMedicine topics:
Adrenal Insufficiency and Adrenal Crisis
Adrenal Disease and Pregnancy
Adrenal Hemorrhage [Endocrinology]
Adrenal Hemorrhage [Radiology]
Adrenal Insufficiency
Septic Shock
Shock, Septic
Clinical guidelines:
Managing asthma during pregnancy: recommendations for pharmacologic treatment.
National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.]. 2005 Jan. 57 pages. NGC:004014
Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine.
Society of Critical Care Medicine - Professional Association. 2008 Jun. 13 pages. NGC:006612
Clinical trials:
Adrenal Insufficiency in Critical Emergencies in Digestive Diseases
Adrenal Insufficiency in Septic Shock
Adrenal Function in Critical Illness
Keywords
adrenal crisis, adrenal insufficiency, cortisol, gland adrenal, adrenal, adrenal gland, cortisol levels, adrenal supplements, acute adrenal crisis, acute adrenal insufficiency, acute adrenocortical insufficiency, Addisonian crisis, adrenal apoplexy, aldosterone, primary adrenocortical insufficiency, secondary adrenocortical insufficiency, bilateral massive adrenal hemorrhage, BMAH, endocrine disorder
