Endocrine · Topic 9 of 13

Adrenal Insufficiency & Adrenal Crisis

Endocrine · adrenal emergency

Adrenal Insufficiency & Adrenal Crisis

Shock that ignores fluids and pressors may be adrenal crisis. Give hydrocortisone 100 mg IV and saline at once — never wait for testing.

Key numbers

Give hydrocortisone 100 mg IV immediatelyHC 100 mg IV/IM

Then hydrocortisone 200 mg/24 h plus saline200 mg/24 h

Low cortisol with ACTH ≥ 50 = primarycortisol < 5 mcg/dL

Cosyntropin test: peak cortisol below 18peak < 18 mcg/dL

01 · FirstGive hydrocortisone 100 mg IV immediately

On suspicion of adrenal crisis, give hydrocortisone 100 mg IV or IM at once. Draw one cortisol and ACTH sample first only if it causes no delay — delaying steroids for testing may be fatal.

02 · DoThen hydrocortisone 200 mg/24 h plus saline

Follow with hydrocortisone 200 mg per 24 hours (continuous infusion or 50 mg IV/IM every 6 hours) and rapid IV 0.9% saline — about 1 L over the first 1–2 hours, with dextrose if hypoglycemic.

03 · Don't confusePrimary: high ACTH, hyperpigmentation, hyperkalemia

Primary adrenal insufficiency (adrenal gland) loses cortisol and aldosterone: ACTH is high, with hyperpigmentation and hyperkalemia. Secondary (ACTH deficiency) spares aldosterone: ACTH is low, no hyperpigmentation, potassium usually normal.

Causes & risk factors

Why it happens

Steroid therapy can suppress the HPA axisGlucocorticoid therapy above the physiologic dose for more than 3–4 weeks can suppress the HPA axis by any route (oral, inhaled, topical, intra-articular); suppression can persist up to a year after stopping.

Treat the precipitant, usually infectionCrisis is usually precipitated by infection (especially sepsis), gastroenteritis, surgery or trauma in a patient with known or unrecognized adrenal insufficiency; recovery depends on treating the trigger.

Primary is usually autoimmuneAbout 90% of US primary adrenal insufficiency is autoimmune; other causes are tuberculosis or fungal infection, adrenal hemorrhage, metastases, amyloidosis and drugs that block cortisol synthesis (ketoconazole, etomidate).

Presentation

What you'll see

Shock refractory to fluids and vasopressors must knowAdrenal crisis presents as hypotension or shock unresponsive to fluids and vasopressors, with profound weakness, abdominal, back or leg pain, vomiting, fever or hypothermia, and confusion; labs show hyponatremia, hyperkalemia, hypoglycemia and azotemia.

Diagnosis & monitoring

Work-up

Low cortisol with ACTH ≥ 50 = primaryA morning cortisol < 5 mcg/dL with ACTH ≥ 50 pg/mL is diagnostic of primary adrenal insufficiency; low cortisol with low ACTH (< 5 pg/mL) suggests secondary.

Do right now

In this order

First moves

Give hydrocortisone 100 mg IV immediatelyHC 100 mg IV/IM

→

Then hydrocortisone 200 mg/24 h plus saline200 mg/24 h

→

Treat the precipitant, usually infection

Why each step

Give hydrocortisone 100 mg IV immediatelyOn suspicion of adrenal crisis, give hydrocortisone 100 mg IV or IM at once. Draw one cortisol and ACTH sample first only if it causes no delay — delaying steroids for testing may be fatal.

Then hydrocortisone 200 mg/24 h plus salineFollow with hydrocortisone 200 mg per 24 hours (continuous infusion or 50 mg IV/IM every 6 hours) and rapid IV 0.9% saline — about 1 L over the first 1–2 hours, with dextrose if hypoglycemic.

Management

Orders

Cosyntropin test: peak cortisol below 18Cosyntropin 250 mcg IV/IM with cortisol at 0, 30 and 60 minutes: a peak < 18 mcg/dL (assay-dependent) indicates adrenal insufficiency. Defer the test until a patient in crisis has recovered.

No fludrocortisone during high-dose hydrocortisoneMineralocorticoid replacement is not needed while high-dose hydrocortisone is given, because hydrocortisone at stress doses has enough mineralocorticoid activity.

Taper to maintenance over 2–3 daysAs the patient improves, reduce hydrocortisone (about 150 mg on day 2 and 75 mg on day 3) to oral maintenance; blood pressure should improve within about 1 hour of the first dose.

Maintenance hydrocortisone plus fludrocortisone (primary)Primary adrenal insufficiency: hydrocortisone 15–25 mg/day in 2–3 doses (largest in the morning) plus fludrocortisone 0.1–0.2 mg daily, titrated to blood pressure and potassium. Glucocorticoid-induced insufficiency does not need fludrocortisone.

Stress-dose any recent steroid userPatients with current or recent glucocorticoid use whose HPA axis has not been tested should get stress-dose coverage for illness or surgery, and adrenal crisis should be considered whatever steroid, route or dose they used.

Red flags & don'ts

Avoid harm

Replace cortisol before thyroid hormone avoidIn hypopituitarism, starting levothyroxine before hydrocortisone can precipitate adrenal crisis because thyroid hormone speeds cortisol clearance.

Primary or secondary adrenal insufficiency?

Commonly confused

ACTH	High
Hyperpigmentation	Yes
Potassium	High (aldosterone lost)
Fludrocortisone	Needed
Typical cause	Autoimmune adrenalitis

Teach & follow up

Patient education

Teach sick-day rules and emergency injectionDouble the glucocorticoid dose during febrile illness, switch to parenteral hydrocortisone if vomiting, carry a 100-mg hydrocortisone injection kit, and wear medical-alert identification.

More detail

Reference

Show 4 reference facts

Suggestive labs in primary disease: sodium < 135 mEq/L, potassium > 5 mEq/L, Na:K ratio < 30:1, low bicarbonate, BUN > 20 mg/dL, eosinophilia and relative lymphocytosis.

Hyponatremia in secondary adrenal insufficiency is dilutional from vasopressin excess rather than salt wasting; electrolytes and BUN are otherwise near normal.

Some centers treat adrenal crisis with equivalent parenteral methylprednisolone or dexamethasone; no head-to-head data exist, and short-term stress dosing is safe even if crisis is later excluded.

Do not taper glucocorticoid courses shorter than 3–4 weeks, whatever the dose; HPA suppression is unlikely.

Pearl

When adrenal crisis is suspected, hydrocortisone comes first — the test can wait, the patient cannot.

Sources · Merck Manual Professional — Primary Adrenal Insufficiency (Addison Disease) (cites the 2016 Endocrine Society guideline) · Beuschlein F et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2024 · Merck Manual Professional — Secondary Adrenal Insufficiency · Synthroid (levothyroxine sodium) prescribing information — DailyMed (§5.4 acute adrenal crisis) · Bornstein SR et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016;101:364–389 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).