Treatment of Adrenal Insufficiency Due to Adrenal Infarct or Hemorrhage

Emergency Management

• The American College of Physicians recommends administering hydrocortisone 100 mg IV immediately upon suspicion of adrenal crisis, followed by fluid resuscitation with 0.9% saline 1
• The Endocrine Society suggests continuing glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1, 2
• Obtain blood samples for cortisol, ACTH, electrolytes, creatinine, urea, and glucose, but do not delay treatment, as recommended by the Journal of Internal Medicine 3, 1
• Investigate and treat the precipitating cause, such as infection or bleeding, as advised by the Journal of Internal Medicine 3, 4

Maintenance Therapy

• The Journal of Internal Medicine recommends hydrocortisone 15-25 mg daily in divided doses for glucocorticoid replacement therapy 5, 3
• The Journal of Internal Medicine suggests using fludrocortisone 50-200 μg daily as a single dose upon awakening for mineralocorticoid replacement therapy 5, 3

Special Situations

• The Journal of Internal Medicine advises administering 100 mg hydrocortisone IM just before anesthesia for major surgery, then 100 mg IM every 6 hours until able to eat and drink 4
• The Journal of Internal Medicine recommends doubling or tripling oral glucocorticoid dose during minor illness with fever 1

Prevention of Future Crises

• The American College of Physicians recommends educating patients on stress dosing during illness or physical stress 1
• The Endocrine Society suggests providing emergency supplies of injectable hydrocortisone and recommending medical alert identification 1
• The Journal of Internal Medicine advises scheduling regular follow-up at least annually to assess health, weight, blood pressure, and electrolytes 3