Medication Summary

Immediately after a serum sample (for cortisol assay) has been obtained, but without awaiting biochemical confirmation, glucocorticoids should be urgently administered to patients with suspected acute, bilateral adrenal hemorrhage in order to prevent or treat acute adrenal insufficiency.

In acutely ill patients, supportive therapy and specific treatments for the underlying condition(s) must be provided urgently as well.

After the acute adrenal hemorrhagic event, long-term glucocorticoid replacement with or without mineralocorticoid replacement therapy may be necessary, based on the results of adrenal function testing.

Class Summary

Administered in a stress-dose regimen, these medications adequately replace glucocorticoid hormone requirements in patients with suspected acute, bilateral adrenal hemorrhage whose adrenal function may be compromised. After discharge, oral prednisone, hydrocortisone, or dexamethasone commonly is used. Only the former 2 glucocorticoids possess some mineralocorticoid properties, whereas dexamethasone is devoid of any such activity.

Hydrocortisone (Solu-Cortef, Hydrocortone, Hydrocort)

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Intravenous hydrocortisone, in conjunction with supportive measures, frequently is used and averts or adequately treats acute adrenal crisis.

Prednisone (Deltasone, Meticorten, Orasone)

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After discharge, oral prednisone commonly is used for maintenance. Possesses some mineralocorticoid properties.

Dexamethasone (Decadron, AK-Dex)

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In conjunction with supportive measures, it is used frequently and averts or adequately treats acute adrenal crisis. Preferred if a Cortrosyn stimulation test is planned soon after the patient has been stabilized, because it does not interfere in a cortisol assay. After discharge, dexamethasone commonly is used for maintenance.

9-alpha-fludrocortisone (Florinef)

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May be indicated in patients with a history of bilateral, extensive adrenal hemorrhage in order to replace mineralocorticoid hormone requirements, based on results of adrenal function testing. Therapy is unnecessary in (acutely ill) patients receiving more than 100 mg of hydrocortisone daily, because this dose also provides adequate mineralocorticoid replacement.

Follow-up

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Media Gallery

Computed tomographic (CT) scans of the abdomen show normal adrenal glands several months before the onset of hemorrhage (upper panel) and enlarged adrenals 2 weeks after an acute episode of bilateral adrenal hemorrhage (lower panel). The attenuation of the adrenal glands, indicated by arrows, is increased after the acute event. Reproduced from Rao RH, Vagnucci AH, Amico JA: Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. Feb 1 1989;110(3):227-35 with permission from the journal.

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