eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Adrenal Insufficiency and Adrenal Crisis: Treatment & Medication

Author: Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Contributor Information and Disclosures

Updated: Aug 19, 2008

Treatment

Emergency Department Care

  • Maintain airway, breathing, and circulation.
  • Employ coma protocol (ie, glucose, thiamine, naloxone).
  • Use aggressive volume replacement therapy (dextrose 5% in normal saline solution [D5NS]).


  • Correct electrolyte abnormalities as follows:
  • Use dextrose 50% as needed for hypoglycemia.
  • Administer hydrocortisone 100 mg IVP q6h. During ACTH stimulation testing, dexamethasone (4 mg IV) can be used instead of hydrocortisone to avoid interference with testing of cortisol levels.
  • Administer fludrocortisone acetate (mineralocorticoid) 0.1 mg qd.
  • Always treat the underlying problem that precipitated the crisis.

Consultations

  • Endocrine consultation following admission is beneficial. If no endocrinologist is available, a general internist can manage the process. Emergency management should be implemented in the ED prior to consultation when sufficient clinical suspicion for this diagnosis exists.
  • ICU admission is necessary for most patients with acute adrenal insufficiency and adrenal crisis.

Medication

One of the goals in treating adrenal insufficiency is glucocorticoid replacement. Electrolyte and metabolic abnormalities, as well as hypovolemia, also must be corrected. In addition, address the event precipitating abrupt decompensation.

Corticosteroids

Used primarily to correct glucocorticoid deficiencies. Drugs of choice are hydrocortisone, cortisone, and prednisone.


Hydrocortisone (Cortef, Solu-Cortef)

DOC because of mineralocorticoid activity and glucocorticoid effects.

Adult

100 mg IV bolus; follow by 100 mg q8h continuous infusion for 24-48 h
Once patient is stable, PO hydrocortisone may be started at 50 mg q8h for another 48 h; may taper dose until dosage is 30-50 mg/d in divided doses
Taper dose over 14 d; discontinue once symptoms resolve

Pediatric

<12 years: 1-2 mg/kg IV bolus; follow by 25-150 mg/d divided q6-8h
>12 years: 1-2 mg/kg IV bolus; follow by 150-250 mg/d divided q6-8h

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

May lower serum potassium levels; complications of hypokalemia (eg, digitalis toxicity) may ensue; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use


Cortisone acetate (Cortone Acetate)

Considered the DOC by some practitioners.

Adult

25-300 mg/d PO/IM divided q12-24h

Pediatric

25-300 mg/d PO/IM divided q12-24h; 0.25-0.35 mg/kg/d IM qd or 12.5 mg/m2/d

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

May lower serum potassium levels; complications of hypokalemia (eg, digitalis toxicity) may ensue; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use


Prednisone (Deltasone, Liquid Pred)

Treats various diseases including adrenocortical insufficiency. Agent is inactive and must be metabolized to active metabolite prednisolone. Conversion may be impaired in patients with liver disease.

Adult

5-60 mg/d PO qd or divided bid/qid

Pediatric

4-5 mg/m2/d PO; alternatively, administer 1-2 mg/kg PO qd; taper over 2 wk as symptoms resolve

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

May lower serum potassium levels; complications of hypokalemia (eg, digitalis toxicity) may ensue; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use


Dexamethasone (Decadron, AK-Dex, Alba-Dex, Dexone)

Alternative to hydrocortisone to avoid interference with testing of cortisol levels.

Adult

4 mg IV; repeat q2-6h if necessary

Pediatric

0.03-0.15 mg/kg/d IV divided q6-12h

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

May lower serum potassium levels; complications of hypokalemia (eg, digitalis toxicity) may ensue; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use


Fludrocortisone acetate (Florinef Acetate)

Partial replacement therapy for primary and secondary adrenocortical insufficiency.

Adult

0.1 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 retention

More on Adrenal Insufficiency and Adrenal Crisis

Overview: Adrenal Insufficiency and Adrenal Crisis
Differential Diagnoses & Workup: Adrenal Insufficiency and Adrenal Crisis
Treatment & Medication: Adrenal Insufficiency and Adrenal Crisis
Follow-up: Adrenal Insufficiency and Adrenal Crisis
References
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References

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Further Reading

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Keywords

adrenal insufficiency, adrenal crisis, adrenocortical insufficiency, severe acute adrenocortical insufficiency, primary adrenocortical insufficiency, primary adrenal insufficiency, secondary adrenocortical insufficiency, secondary adrenal insufficiency, suppression of the hypothalamic-pituitary axis, mineralocorticoid function, glucocorticoid, hypopituitarism, cortisol, aldosterone, pan-hypopituitarism, panhypopituitarism, Sheehan syndrome, endocrinedisorders, adrenocorticotropic hormone, ACTH,adrenocorticotropic hormone deficiency

ACTH deficiency, postpartum pituitary infarction, hypothalamic-pituitary disease, hypothyroidism, physiologic effects of glucocorticoids, physiologic effects of aldosterone, tuberculosis of adrenal gland, fungal infection of adrenal gland, idiopathic atrophy of adrenal gland, congenital adrenal hyperplasia, adrenal hemorrhage, septicemia-induced Waterhouse-Friderichsen syndrome, fulminant meningococcemia, steroid withdrawal, autoimmune adrenaldestruction,polyglandular autoimmune disorders, PGAs, Schmidt syndrome, idiopathic autoimmune adrenal insufficiency, myocardial infarction, psychoses, depression, hypoglycemia, alcohol abuse, hypothermia, asthma

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Contributor Information and Disclosures

Author

Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Kevin M Klauer, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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