Adrenal Insufficiency Emergency Management

Introduction to Emergency Hydrocortisone

The American College of Endocrinology recommends that every patient with primary or secondary adrenal insufficiency be prescribed an emergency injectable hydrocortisone 100 mg kit for home use, with training provided to both the patient and family members on self-administration during impending adrenal crisis 1, 2, 3, 4.

Adrenal crises occur at a rate of 6-8 episodes per 100 patient-years, with a mortality rate of 0.5 per 100 patient-years when treatment is delayed, according to the Endocrine Society 2, 3.
Patients who cannot access emergency medical care within 30-60 minutes require the ability to self-administer parenteral hydrocortisone to prevent death, as stated by the American Academy of Clinical Endocrinologists 1, 2.

The European Society of Endocrinology recommends administering the 100 mg hydrocortisone injection immediately if the patient experiences persistent vomiting or severe diarrhea preventing oral medication absorption 1, 2, 4.
The American College of Endocrinology suggests administering the injection for severe weakness, confusion, or altered mental status 1, 6.
The injection is also recommended for hypotension with lightheadedness or loss of consciousness, according to the Endocrine Society 1, 4, 6.

The 100 mg hydrocortisone should be administered intramuscularly or intravenously if the patient or family member has been trained, as recommended by the American Academy of Clinical Endocrinologists 1, 4.
After injection, immediately call emergency services and inform them the patient has adrenal insufficiency and has received hydrocortisone, according to the European Society of Endocrinology 1, 5, 6.

Patients should double or triple their usual oral hydrocortisone dose during febrile illness, moderate illness, or minor surgical procedures, as recommended by the Endocrine Society 1, 2, 4.
The American College of Endocrinology suggests doubling the daily dose for febrile illness and doubling to tripling the daily dose for moderate illness 1, 2, 4, 5.

All patients must wear a medical alert bracelet or necklace stating "adrenal insufficiency" to trigger immediate stress-dose corticosteroids by emergency personnel, according to the American Academy of Clinical Endocrinologists 1, 2, 5, 6.
Patients and family members must receive hands-on training in preparing and administering the emergency injection, with periodic refresher training, as recommended by the European Society of Endocrinology 1, 2.

Standard maintenance dosing is hydrocortisone 15-25 mg daily in divided doses to mimic physiological cortisol rhythm, according to the Endocrine Society 4, 5.
The 100 mg emergency dose represents 4-7 times the daily maintenance dose and is appropriate for life-threatening stress, as stated by the American College of Endocrinology 4, 6.