Adequate treatment of adrenal crisis (AC) is often delayed, even when a h/o adrenal insufficiency is known.

• most important predictor of AC is a h/o of AC

 

Besides refractory hypotension, also consider in pts with:

• critically ill pts with eosinophilia (cortisol typically suppresses eosinophil counts)
• cancer patients who are on check-point inhibitor immunotherapy (they can cause severe hypophysitis or adrenalitis)
• (inhaled glucocorticoids and topical creams also cause a degree of adrenal insufficiency)

 

Beware of triggers:

• trauma, recent surgery, even emotional stress/exercise
• recent initiation of medications that increase hydrocortisone metabolism (avasimibe, carbamazepine, rifampicin, phenytoin, and St. John’s wort extract)
• recent withdrawal of medications that decrease hydrocortisone metabolism (voriconazole, grapefruit juice, itraconazole, ketoconazole, clarithromycin, lopinavir, nefazodone, posaconazole, ritonavir, saquinavir, telaprevir, telithromycin, and conivaptan)

 

Treatment:

• 100 mg IV hydrocortisone STAT as a loading dose, followed by 50 mg IV hydrocortisone q6h
• can also give 40 mg IV methylprednisolone if hydrocortisone is not immediately available
• can also give 4-6 mg IV decadron instead (will preserve integrity of ACTH stim test to diagnose adrenal insufficiency if it is performed later)

 

References

Amrein K, Martucci G, Hahner S. Understanding adrenal crisis. Intensive Care Med. 2018;44(5):652-655.

Rushworth RL, Torpy DJ, Falhammar H. Adrenal Crisis. N Engl J Med. 2019;381(9):852-861.