In this article, we will discuss the Treatment of Acute Adrenal Crisis/Insufficiency. So, let’s get started.
- Fluid replacement: Large volume of 5% dextrose in saline or 0.9% normal saline (1L/hr) should be infused immediately with continuous cardiac monitoring.
- Steroid replacement therapy: Intravenous hydrocortisone mg IV as a bolus or dexamethasone mg IV stat, followed by a continuous infusion of hydrocortisone at a rate of 10 mg/hour. An alternative approaches to give 100 mg IV hydrocortisone as a bolus, then 100 mg IV after every 6 hours for first day, then same dose is given 8 hourly for second day until gastrointestinal symptoms abate and patient start accepting orally. Dexamethasone is preferred because its effect lasts for 12-24 hours and it does not interfere with measurement of plasma or urinary steroids during subsequent ACTH stimulation test.
- Treatment of hypotension of shock: Effective treatment of hypotension or shock requires glucocorticoid replacement and repletion of sodium and water deficits. Vasoactive agents (e.g. dopamine) may be indicated in severe hypotension as an adjuvant to fluid therapy.
- No need for mineralocorticoid replacement: With large doses of steroids e.g. 100 to 200 mg hydrocortisone, the patient receives a maximal mineralocorticoid effect, hence, supplementation of mineralocorticoid will be superfluous.
- Identification of precipitating cause and its treatment: Since bacterial infection frequently precipitate acute adrenal crisis, broad-spectrum antibiotic should be administered empirically while waiting for culture reports. The patient must also be treated for electrolyte abnormalities, hypoglycemia and dehydration. Following improvement, the steroid dosage is tapered over next few days to maintenance levels, and mineralocorticoid therapy is reinstituted. Most patients who present with acute adrenal insufficiency have deficiency of both glucocorticoids and mineralocorticoids, hence, in addition to maintenance dose of glucocorticoids (7.5 to 10 mg/day), a life-long replacement of mineralocorticoid (fludrocortisone 0.05 to 0.1 mg/day) orally can be started as soon as saline drip is stopped and patient accepts orally.