Adrenal Crisis in Cancer Patients

Cancer as a Direct Cause of Adrenal Insufficiency

Secondary adrenal insufficiency can result directly from brain tumors and their treatment, particularly in pediatric populations where pituitary or hypothalamic tumors cause ACTH deficiency, according to the American Society of Anesthesiologists 1
Metastatic disease to the adrenal glands can cause primary adrenal insufficiency and should be evaluated with adrenal CT imaging when autoantibodies are negative, as recommended by the American Society of Clinical Oncology 2
Brain tumors affecting the hypothalamus or pituitary can cause secondary adrenal insufficiency through ACTH deficiency, as reported in the journal Anaesthesia 1, 4

Approximately seven in 1000 people are prescribed long-term oral corticosteroid therapy, creating a population 100 times larger than those with intrinsic adrenal insufficiency and at substantial risk for adrenal crisis, according to the American Society of Anesthesiologists 5
Glucocorticoid therapy across all routes of administration (oral, inhaled, topical, intranasal, intra-articular) can suppress the hypothalamo-pituitary-adrenal axis, as reported in the journal Anaesthesia 5, 6
Surgical episodes for cancer treatment are documented precipitating factors for adrenal crisis, as reported in the journal Anaesthesia 5, 6

Any cancer patient taking ≥20 mg/day prednisone or equivalent for at least 3 weeks who develops unexplained hypotension should be presumed to have adrenal insufficiency until proven otherwise, according to the Endocrine Society 3
Unexplained collapse, hypotension, and gastrointestinal symptoms (vomiting or diarrhea) should immediately raise suspicion for adrenal crisis, as recommended by the Endocrine Society 3
Hyponatremia is present in 90% of newly diagnosed adrenal insufficiency cases, though hyperkalemia occurs in only ~50% of cases and its absence cannot rule out the diagnosis, as reported in the journal Praxis Medical Insights 3
Treatment of suspected acute adrenal insufficiency should NEVER be delayed for diagnostic procedures, according to the American Society of Clinical Oncology and the Endocrine Society 2, 3, 7
Immediate management: Administer hydrocortisone 100 mg IV bolus immediately without waiting for test results, as recommended by the American Society of Clinical Oncology and the Endocrine Society 2, 7
Fluid resuscitation: Infuse 0.9% saline at 1 L/hour (at least 2L total), as recommended by the American Society of Clinical Oncology and the Endocrine Society 2, 7

Patients must wear a medical alert bracelet indicating adrenal insufficiency, as recommended by the American Society of Clinical Oncology and the Endocrine Society 2, 7
Educate patients to double or triple their dose during illness, fever, or physical stress, as recommended by the Endocrine Society 8, 7
Provide training on emergency injectable hydrocortisone 100 mg IM kit with self-injection instruction, as recommended by the Endocrine Society 8, 7