Adrenal crisis

Background

Adrenal insufficiency occurs when the adrenal glands fail to supply the physiologic demands of the body for glucocorticoids (cortisol) and/or mineralocorticoids (aldosterone).
Divided into primary adrenal insufficiency or secondary adrenal insufficiency
Adrenal crisis is the acute, life-threatening presentation of adrenal insufficiency^[1]
- 8-47% of patients with primary adrenal insufficiency will have at least one adrenal crisis in their lives
- Consider in any patient with unexplained hypotension (especially in those with HIV or taking exogenous steroids)
- Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
  - This is the reason crises occur much more frequently with primary adrenal insufficiency

Secondary Adrenal Insufficiency
- Similar to primary adrenal insufficiency
- No hyperpigmentation
- No hyperkalemia
- Hypotension less common

Labs
- CBC - eosinophilia^[5]
- Chemistry
- Random cortisol, renin, and ACTH levels
  - Do not wait for levels before starting treatment
- ACTH (cosyntropin) stimulation test

Begin treatment immediately in any suspected case (prognosis related to rapidity of treatment)

Treat underlying cause, if known
IVF - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
Steroids
- Hydrocortisone - 2mg/kg up to 100mg IV bolus
  - Drug of choice if K+>6 (provides glucocorticoid and mineralocorticoid effects)
- Dexamethasone - 4mg IV bolus
  - Consider in hemodynamically stable patients if ACTH stimulation test will be performed (will not interfere with the test)
  - Along with methylprednisolone, dexamethasone has negligible mineralocorticoid effect, so choose hydrocortisone in^[6]:
    - Hypotension
    - Hyponatremia or hyperkalemia
- Comparable steroid dosages
  - Hydrocortisone (50-75mg/m2 or 1-2mg/kg)
  - Methylprednisolone are 10-15mg/m2
  - Dexamethasone 1-1.5mg/m2
Vasopressors
- Administer after steroid therapy in patients unresponsive to fluid resuscitation

To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol

Illness Type	Steroid Administration
Minor, with fever < 38°C	Double dose of chronic maintenance steroids
Severe, with fever > 38°C	Triple dose of chronic maintenance steroids
Vomiting, listless, or hypotensive	Hydrocortisone at 1-2mg/kg (as above in adrenal crisis)

Admission
- Admit all patients with acute adrenal insufficiency, especially if new diagnosis for the patient
- Patients with adrenal crisis should receive ICU admission
Discharge
- Consult endocrinology if discharge considered for mild cases w/ normal lab values

↑ Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884
↑ Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. 1989;110(3):227-235. doi:10.7326/0003-4819-110-3-227
↑ Izumi Y et al. Renal tubular acidosis complicated with hyponatremia due to cortisol insufficiency. Oxf Med Case Reports. 2015 Nov; 2015(11): 360–363.
↑ Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
↑ Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.
↑ Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013. http://emedicine.medscape.com/article/918967-medication.

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