Addisonian Crisis
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ADRENAL CRISIS (ADDISONIAN CRISIS) – EMERGENCY PROTOCOL
CLINICAL MANAGEMENT GUIDELINE – INDIA
🚨 MEDICAL EMERGENCY | IMMEDIATE TREATMENT REQUIRED
Mortality: 0.5-2% per crisis episode; Higher if delayed treatment
This is a CLINICAL diagnosis – TREAT FIRST, Confirm Later
Do NOT wait for lab results to initiate treatment
🔰 SYMBOL LEGEND
| Symbol | Meaning |
| 🚨 | Emergency / Critical |
| ✅ | Recommended / First-line |
| ⚠️ | Caution / Important |
| ❌ | Contraindicated / Avoid |
| 💊 | Drug |
| 🇮🇳 | India-specific |
| ⏱️ | Time-critical |
SECTION 1: RECOGNITION
1.1 DEFINITION
🚨 Adrenal Crisis (Addisonian Crisis) = Life-threatening medical emergency due to acute cortisol deficiency, characterized by:
-
- Severe hypotension / Shock (refractory to fluids and vasopressors)
- Volume depletion
- Often with precipitating event
📌 Can occur in KNOWN adrenal insufficiency (most common) OR as FIRST presentation
1.2 WHO IS AT RISK?
Patients with Known Adrenal Insufficiency
| Condition |
|
Primary adrenal insufficiency (Addison’s disease)
|
|
Secondary adrenal insufficiency (Pituitary disease)
|
|
Tertiary adrenal insufficiency (Chronic steroid use → HPA suppression)
|
|
Bilateral adrenalectomy
|
|
Congenital adrenal hyperplasia (CAH)
|
Patients Without Known Diagnosis (First Presentation)
| Scenario |
| Undiagnosed Addison’s disease |
| Pituitary apoplexy |
| Bilateral adrenal hemorrhage (Waterhouse-Friderichsen) |
| Acute illness in patient with unrecognized adrenal insufficiency |
1.3 PRECIPITANTS – THE TRIGGER
📌 Crisis is almost ALWAYS precipitated by a stressor in patients with adrenal insufficiency
| 🚨 Common Precipitants |
|
Infection (most common) – Gastroenteritis, Respiratory, UTI, Sepsis
|
|
Non-compliance / Discontinuation of glucocorticoid replacement
|
|
Inadequate stress dosing during illness/surgery
|
|
Vomiting / Diarrhea (cannot absorb oral steroids)
|
|
Surgery / Trauma without adequate steroid cover
|
|
Severe physical stress
|
|
Emotional stress (less common precipitant)
|
| Other Precipitants |
| Adrenal hemorrhage (anticoagulants, sepsis, trauma) |
| Pituitary apoplexy |
| Drugs: Ketoconazole, Etomidate, Rifampicin (↑ cortisol metabolism), Phenytoin, Checkpoint inhibitors |
| Pregnancy / Labor |
| Burns |
| Myocardial infarction |
| Hyperthyroidism treatment (↑ cortisol clearance) |
1.4 CAUSES OF ADRENAL INSUFFICIENCY LEADING TO CRISIS
Primary Adrenal Insufficiency
| Cause | Notes |
|
Autoimmune adrenalitis
|
Most common in developed countries |
|
Tuberculosis
|
Most common in India
|
|
Adrenal hemorrhage
|
Anticoagulants, Sepsis (Waterhouse-Friderichsen), Trauma |
|
Bilateral adrenalectomy
|
|
|
Metastatic disease
|
Lung, Breast, Melanoma |
|
Infections
|
Fungal (Histoplasma), HIV/CMV |
|
Congenital adrenal hyperplasia
|
|
|
Adrenoleukodystrophy
|
|
|
Drugs
|
Ketoconazole, Etomidate |
Secondary/Tertiary Adrenal Insufficiency
| Cause | Notes |
|
Chronic glucocorticoid therapy
|
Most common cause overall
|
|
Pituitary tumors / Surgery / Radiation
|
|
|
Pituitary apoplexy
|
Acute |
|
Sheehan syndrome
|
Postpartum pituitary necrosis |
|
Hypophysitis
|
Autoimmune, Checkpoint inhibitor-induced |
|
Hypothalamic disease
|
|
|
Traumatic brain injury
|
SECTION 2: CLINICAL FEATURES
2.1 CARDINAL FEATURES
| 🚨 Feature | Description |
|
Hypotension / Shock
|
Often refractory to fluids and vasopressors |
|
Volume depletion
|
Dehydration |
|
Altered consciousness
|
Confusion, Lethargy, Obtundation, Coma |
|
Abdominal symptoms
|
Pain, Nausea, Vomiting (may mimic acute abdomen) |
|
Precipitating event
|
Usually identifiable |
2.2 SYMPTOMS
Cardiovascular
| Symptom |
|
Dizziness / Lightheadedness
|
|
Syncope / Near-syncope
|
|
Palpitations (compensatory tachycardia)
|
Gastrointestinal
| Symptom | Notes |
|
Nausea
|
Very common |
|
Vomiting
|
May precipitate crisis (can’t absorb oral meds) |
|
Abdominal pain
|
Can be severe; May mimic acute abdomen |
|
Diarrhea
|
|
|
Anorexia
|
Neurological
| Symptom |
|
Weakness (profound)
|
|
Fatigue (severe)
|
|
Confusion
|
|
Lethargy
|
Other
| Symptom |
|
Fever (if infection precipitant; Or due to crisis itself)
|
|
Leg cramps / Myalgia (electrolyte disturbances)
|
2.3 SIGNS
Vital Signs
| Sign | Finding |
|
Blood pressure
|
↓↓ Hypotension; Often < 90/60 mmHg |
|
Postural hypotension
|
Marked drop on standing |
|
Heart rate
|
↑ Tachycardia (compensatory) |
|
Temperature
|
↑ Fever (infection) OR ↓ Hypothermia |
|
Respiratory rate
|
May be increased |
General Examination
| Sign | Notes |
|
Dehydration
|
Dry mucous membranes, Reduced skin turgor, Sunken eyes |
|
Shock
|
Cold peripheries, Delayed capillary refill, Weak pulse |
|
Altered consciousness
|
Confusion → Obtundation → Coma |
|
Hyperpigmentation
|
PRIMARY AI only – Palmar creases, Buccal mucosa, Scars, Pressure points
|
|
Vitiligo
|
May be present (autoimmune association) |
|
Abdominal tenderness
|
May mimic acute abdomen |
|
Absent axillary/pubic hair
|
Women with chronic AI |
Signs by Underlying Cause
| Sign | Suggests |
|
Hyperpigmentation
|
PRIMARY adrenal insufficiency (high ACTH) |
|
NO hyperpigmentation
|
SECONDARY/TERTIARY (low ACTH) |
|
Visual field defect
|
Pituitary tumor |
|
Bilateral adrenal mass/hemorrhage on imaging
|
Adrenal hemorrhage/metastases |
|
Signs of underlying infection
|
Precipitant |
2.4 CLASSIC PRESENTATION SCENARIOS
Scenario 1: Known Addison’s Disease + Illness
| Features |
| Patient with known primary AI |
| Develops gastroenteritis (vomiting, diarrhea) |
| Unable to take/absorb oral hydrocortisone |
| Develops hypotension, Weakness, Confusion |
|
Diagnosis: Adrenal crisis due to GI illness
|
Scenario 2: Patient on Chronic Steroids + Surgery
| Features |
| Patient on long-term prednisolone for RA/Asthma |
| Undergoes surgery WITHOUT stress dose steroids |
| Post-operatively develops hypotension, Shock |
| Refractory to fluids and vasopressors |
|
Diagnosis: Adrenal crisis due to inadequate steroid cover
|
Scenario 3: First Presentation
| Features |
| Previously healthy (or chronic fatigue, Weight loss) |
| Develops severe infection |
| Presents with shock, Hyperpigmentation |
| Hypotension refractory to treatment |
| Hyponatremia, Hyperkalemia |
|
Diagnosis: Adrenal crisis as first presentation of Addison’s
|
Scenario 4: Waterhouse-Friderichsen Syndrome
| Features |
| Severe sepsis (especially Meningococcal) |
| Bilateral adrenal hemorrhage |
| Rapid deterioration, Purpura, DIC |
| Refractory shock |
|
Diagnosis: Adrenal crisis due to adrenal hemorrhage
|
2.5 CLINICAL CLUES TO ADRENAL CRISIS
| 🚩 Red Flags – Think Adrenal Crisis If: |
|
Shock refractory to fluids and vasopressors
|
|
Hypotension + Hyponatremia + Hyperkalemia
|
|
Hyperpigmentation
|
|
History of adrenal/pituitary disease
|
|
History of chronic steroid use
|
|
Recent steroid withdrawal
|
|
Hypoglycemia (especially with hypotension)
|
|
Unexplained fever + Hypotension
|
|
Abdominal pain + Hypotension + Confusion
|
SECTION 3: DIAGNOSIS
3.1 CLINICAL DIAGNOSIS
| 🚨 CRITICAL PRINCIPLE |
|
ADRENAL CRISIS IS A CLINICAL DIAGNOSIS
|
|
TREAT FIRST – Confirm Later
|
| Do NOT wait for lab results |
| Delay in treatment = Increased mortality |
Clinical Diagnostic Criteria
| Criteria |
| Acute deterioration in health status |
|
PLUS Hypotension (SBP < 100 mmHg) or Shock
|
|
PLUS Features that resolve with parenteral glucocorticoid
|
|
WITH Underlying adrenal insufficiency (known or suspected)
|
3.2 LABORATORY FINDINGS
Electrolytes
| Finding | Mechanism | Notes |
|
Hyponatremia
|
↓ Aldosterone (Na+ loss); ↓ Cortisol (↑ ADH) | Common in PRIMARY |
|
Hyperkalemia
|
↓ Aldosterone (K+ retention) | Common in PRIMARY |
|
Metabolic acidosis
|
↓ Aldosterone (H+ retention) | |
|
Normal electrolytes
|
May occur in SECONDARY (aldosterone intact) |
Glucose
| Finding | Notes |
|
Hypoglycemia
|
↓ Gluconeogenesis; More common in children and secondary AI |
Renal Function
| Finding | Mechanism |
|
Elevated urea
|
Dehydration; Prerenal |
|
Elevated creatinine
|
Dehydration; Prerenal |
Other
| Test | Finding |
|
Calcium
|
May be elevated |
|
CBC
|
Eosinophilia; Lymphocytosis; Anemia (chronic) |
|
TSH
|
May be elevated (cortisol needed for TSH suppression) |
3.3 HORMONAL CONFIRMATION (When Stable)
📌 Draw blood for cortisol BEFORE giving steroids if possible, but DO NOT DELAY TREATMENT
Cortisol
| Test | Interpretation |
|
Random cortisol
|
Should be HIGH in acute illness/stress |
| < 3 μg/dL (83 nmol/L) = AI very likely | |
| < 10 μg/dL (276 nmol/L) in critically ill = AI likely | |
| < 15-18 μg/dL (414-500 nmol/L) in acute stress = Inappropriate | |
| > 18-20 μg/dL (500-550 nmol/L) = AI unlikely |
ACTH
| Finding | Interpretation |
|
↑↑ High ACTH + ↓ Cortisol
|
PRIMARY adrenal insufficiency |
|
↓ or Normal ACTH + ↓ Cortisol
|
SECONDARY/TERTIARY (Central) |
Confirmatory Testing (Once Stable)
| Test | Protocol |
|
Short Synacthen Test (ACTH Stimulation)
|
Give Synacthen 250 μg IV/IM; Measure cortisol at 0, 30, 60 min |
|
Interpretation
|
Peak cortisol < 18-20 μg/dL (500 nmol/L) = AI confirmed |
3.4 DISTINGUISHING PRIMARY VS SECONDARY AI
| Feature | Primary AI | Secondary AI |
|
ACTH
|
↑↑ | ↓ or Normal |
|
Aldosterone
|
↓ |
Normal
|
|
Hyponatremia
|
✅ Common | May occur (dilutional) |
|
Hyperkalemia
|
✅ Common | ❌ Absent (aldosterone intact) |
|
Hyperpigmentation
|
✅ Present | ❌ Absent |
|
Salt craving
|
✅ Present | ❌ Absent |
3.5 ADDITIONAL INVESTIGATIONS
| Investigation | Purpose |
|
ECG
|
Hyperkalemia changes; Arrhythmias |
|
CXR
|
Infection; Small heart (chronic AI) |
|
Blood cultures
|
Infection workup |
|
Urine analysis/culture
|
UTI |
|
Blood glucose
|
Hypoglycemia |
|
CT Adrenals
|
Hemorrhage, Calcification (TB), Masses |
|
CT/MRI Pituitary
|
If secondary AI suspected |
SECTION 4: MANAGEMENT – OVERVIEW
4.1 Treatment Principles
🚨 Adrenal Crisis Management
⏱️ Time-Critical: Treat Immediately
Do NOT wait for laboratory results before starting treatment.
Step 1: IV Hydrocortisone
💊 100 mg IV bolus immediately
Then 50–100 mg IV every 6–8 hours
OR 200 mg continuous IV infusion over 24 hours
Step 2: IV Fluids
Administer 0.9% Normal Saline for aggressive fluid resuscitation
-
1 liter in the first hour
-
4–6 liters during the first 24 hours
Step 3: Treat Hypoglycemia
Check blood glucose levels.
If hypoglycemia is present, give IV Dextrose immediately.
Step 4: Identify and Treat Precipitating Cause
Identify the underlying trigger.
Most common cause: Infection
Start appropriate antibiotics if infection is suspected.
Step 5: Monitor and Taper
Closely monitor:
-
Vital signs
-
Electrolytes
-
Blood glucose
Once the patient is clinically stable, transition to oral maintenance steroid therapy.
4.2 KEY POINTS
| 🚨 Critical Points |
|
Hydrocortisone is life-saving – Give IMMEDIATELY
|
|
High-dose hydrocortisone has mineralocorticoid activity – No need for fludrocortisone acutely
|
|
Aggressive IV fluids – These patients are severely volume depleted
|
|
Treat the precipitant – Usually infection
|
|
Do NOT use dexamethasone if you need to do ACTH stim test later (dexamethasone doesn’t cross-react with cortisol assay; hydrocortisone does – but treatment takes priority)
|
SECTION 5: STEP-BY-STEP MANAGEMENT
STEP 1: HYDROCORTISONE – IMMEDIATE
5.1 Initial Bolus
| 💊 Drug | Dose | Route | Timing |
|
Hydrocortisone sodium succinate
|
100 mg
|
IV bolus
|
IMMEDIATELY
|
5.2 Maintenance
| Regimen | Dose |
|
Intermittent bolus
|
50-100 mg IV q6-8h
|
|
OR Continuous infusion
|
200 mg IV over 24 hours (8.3 mg/hr)
|
5.3 Why Hydrocortisone?
| Advantage |
| ✅ Has BOTH glucocorticoid AND mineralocorticoid activity |
| ✅ At high doses (≥ 50 mg), mineralocorticoid effect is sufficient |
| ✅ No need for separate fludrocortisone in acute phase |
| ✅ Rapid onset |
| ✅ Widely available |
5.4 Alternative Glucocorticoids (If Hydrocortisone Unavailable)
| 💊 Drug | Dose | Notes |
|
Dexamethasone
|
4 mg IV
|
⚠️ NO mineralocorticoid activity; May need fludrocortisone in primary AI |
| ✅ Use if ACTH stim test planned (doesn’t interfere with cortisol assay) | ||
|
Methylprednisolone
|
40 mg IV
|
Minimal mineralocorticoid activity |
|
Prednisolone
|
25 mg IV/PO
|
Less preferred; Oral absorption may be impaired |
5.5 Glucocorticoid Equivalence
| Drug | Equivalent Dose | Mineralocorticoid Activity |
| Hydrocortisone 100 mg | – | ✅ Yes |
| Prednisolone 25 mg | ≈ | Minimal |
| Methylprednisolone 20 mg | ≈ | None |
| Dexamethasone 4 mg | ≈ | None |
STEP 2: IV FLUID RESUSCITATION
5.6 Fluid Choice
| 💧 Fluid | Recommendation |
|
0.9% Normal Saline
|
✅ First-line
|
|
5% Dextrose in Normal Saline
|
✅ If hypoglycemic |
5.7 Fluid Volume
| Time | Volume |
|
First hour
|
1000 mL (rapid bolus)
|
|
First 4-6 hours
|
2-3 L
|
|
First 24 hours
|
4-6 L (guided by response)
|
5.8 Why Aggressive Fluids?
| Rationale |
| Patients are severely volume depleted |
| Aldosterone deficiency (PRIMARY AI) → Sodium and water loss |
| Vomiting/diarrhea worsen dehydration |
| Hypotension is primarily due to volume depletion |
5.9 Fluid Monitoring
| Monitor |
|
Urine output – Target > 0.5 mL/kg/hr
|
|
Blood pressure – Target MAP > 65 mmHg
|
|
Heart rate – Should decrease with resuscitation
|
|
Clinical perfusion – Capillary refill, Skin temperature
|
|
⚠️ Avoid overload in elderly/cardiac patients
|
STEP 3: CORRECT HYPOGLYCEMIA
5.10 Management
| If Hypoglycemic |
|
50 mL of 50% Dextrose IV bolus (25 g)
|
|
OR 100-200 mL of 25% Dextrose
|
|
OR 500 mL of 10% Dextrose
|
|
Switch to Dextrose-containing maintenance fluids (D5NS)
|
| Monitor glucose q1-2 hours initially |
STEP 4: IDENTIFY AND TREAT PRECIPITANT
5.11 Search for Precipitant
| Investigation |
| History: Infection, Missed doses, Surgery, Trauma |
| Examination: Source of infection |
| Blood cultures |
| Urine analysis and culture |
| CXR |
| Other directed investigations |
5.12 Treat Infection
| If Infection Suspected |
|
Empiric broad-spectrum antibiotics
|
| Do NOT delay antibiotics |
| Adjust based on culture results |
| Common Regimens |
|
Community-acquired: Ceftriaxone 2 g IV + Azithromycin (if respiratory)
|
|
Urinary source: Ceftriaxone or Fluoroquinolone
|
|
Sepsis/Unknown: Piperacillin-tazobactam or Meropenem
|
STEP 5: ADDITIONAL MEASURES
5.13 Vasopressors
| When to Use |
|
If hypotension persists despite adequate fluids and hydrocortisone
|
|
💊 Noradrenaline – First-line vasopressor
|
| Start at 0.05-0.1 μg/kg/min; Titrate to MAP > 65 mmHg |
| ⚠️ Important |
|
Hypotension in adrenal crisis is often refractory to vasopressors UNTIL glucocorticoid given
|
| Response to vasopressors improves after hydrocortisone |
5.14 Correct Electrolyte Abnormalities
| Abnormality | Management |
|
Hyponatremia
|
Usually corrects with IV NS + Hydrocortisone; Do NOT use hypertonic saline unless severe/symptomatic |
|
Hyperkalemia
|
Usually corrects with IV NS + Hydrocortisone; Standard hyperkalemia treatment if severe (Calcium gluconate, Insulin-dextrose, Salbutamol) |
5.15 Monitor for Complications
| Complication | Management |
|
Arrhythmias (Hyperkalemia)
|
ECG monitoring; Treat hyperkalemia |
|
Seizures (Hypoglycemia, Hyponatremia)
|
Correct glucose and sodium; Benzodiazepines |
|
Shock (Refractory)
|
Vasopressors; Ensure adequate steroid dose |
SECTION 6: MONITORING
6.1 ACUTE PHASE MONITORING
| Parameter | Frequency | Target |
|
Blood pressure
|
Continuous / q15 min initially | SBP > 100; MAP > 65 |
|
Heart rate
|
Continuous | Decreasing (compensation reducing) |
|
Urine output
|
Hourly | > 0.5 mL/kg/hr |
|
Oxygen saturation
|
Continuous | > 94% |
|
Temperature
|
q2-4 hours | Monitor for fever (infection) |
|
Glucose
|
q1-2 hours initially | > 70 mg/dL |
|
Sodium
|
q6-12 hours | Gradual normalization |
|
Potassium
|
q6-12 hours | < 5.5 mEq/L |
|
Mental status
|
Frequent | Improving |
6.2 EXPECTED CLINICAL RESPONSE
| Time | Expected Response |
|
1-2 hours
|
Blood pressure improving |
|
4-6 hours
|
Significant hemodynamic improvement |
|
12-24 hours
|
Clinical stabilization |
|
24-72 hours
|
Resolution of acute crisis |
|
Days
|
Electrolytes normalizing |
6.3 SIGNS OF IMPROVEMENT
| ✅ Improving |
| Blood pressure rising |
| Heart rate decreasing |
| Urine output increasing |
| Mental status clearing |
| Sodium rising |
| Potassium falling |
| Glucose stable |
6.4 SIGNS OF NON-RESPONSE / DETERIORATION
| 🚨 Worsening |
| Persistent hypotension despite treatment |
| Worsening mental status |
| Oliguria / Anuria |
| Worsening metabolic acidosis |
| Uncontrolled hyperkalemia |
| Action |
| Ensure adequate hydrocortisone dose |
| Ensure adequate fluid resuscitation |
| Consider alternative diagnosis |
| Escalate care (ICU if not already) |
| Look for uncontrolled precipitant |
SECTION 7: TAPERING AND TRANSITION
7.1 WHEN TO TAPER
| Criteria to Begin Taper |
| Hemodynamically stable |
| Eating and drinking |
| Precipitant controlled |
| Electrolytes improving |
|
Usually after 24-72 hours
|
7.2 TAPERING PROTOCOL
| Day | Hydrocortisone Dose |
|
Day 1 (Crisis)
|
100 mg IV bolus → 50-100 mg q6-8h |
|
Day 2
|
50 mg IV/PO q6-8h (150-200 mg/day) |
|
Day 3
|
25-50 mg PO q6-8h (75-150 mg/day) |
|
Day 4
|
20 mg AM + 10 mg Noon + 10 mg PM (40 mg/day) |
|
Day 5
|
20 mg AM + 10 mg PM (30 mg/day) |
|
Day 6+
|
Return to maintenance (15-25 mg/day) |
7.3 TRANSITION TO ORAL MAINTENANCE
Oral Hydrocortisone Regimen
| 💊 Hydrocortisone | Typical Maintenance |
|
Dose
|
15-25 mg/day |
|
Regimen
|
10 mg AM + 5 mg Noon + 5 mg Late afternoon |
|
OR
|
15 mg AM + 5 mg Afternoon |
Add Fludrocortisone (PRIMARY AI Only)
| 💊 Fludrocortisone | Dose |
|
When to start
|
Once hydrocortisone < 50 mg/day |
|
Dose
|
0.05-0.2 mg once daily (usually 0.1 mg)
|
|
Not needed in
|
Secondary/Tertiary AI (aldosterone intact) |
7.4 DISCHARGE CRITERIA
| ✅ Ready for Discharge |
| Hemodynamically stable on oral medication |
| Tolerating oral intake |
| Precipitant treated/controlled |
| Electrolytes stable |
| Patient/Family educated on sick day rules |
| Emergency injection kit provided |
| Medical alert identification arranged |
| Follow-up appointment scheduled |
SECTION 8: PREVENTION OF FUTURE CRISES
8.1 SICK DAY RULES – PATIENT EDUCATION
Mild Illness (Cold, Minor Infection, Low-grade Fever)
| Rule |
|
DOUBLE the usual hydrocortisone dose
|
| Continue fludrocortisone unchanged |
| Increase fluid and salt intake |
| Continue until recovered |
| Return to normal dose when well |
Moderate Illness (Higher Fever, Vomiting, Diarrhea)
| Rule |
|
TRIPLE the usual hydrocortisone dose
|
|
If unable to keep oral meds down → Injectable hydrocortisone
|
| Seek medical attention |
Severe Illness / Emergency
| 🚨 Rule |
|
100 mg Hydrocortisone IM/IV immediately
|
|
Then 50-100 mg every 6-8 hours
|
|
Seek emergency medical care
|
8.2 STRESS DOSING FOR PROCEDURES
| Procedure | Recommendation |
|
Minor (Dental work)
|
Double dose on morning of procedure |
|
Moderate (Endoscopy)
|
50 mg IV/IM before procedure; Double oral × 24-48h |
|
Major surgery
|
100 mg IV pre-op → 50-100 mg IV q8h → Taper over 3-5 days |
8.3 EMERGENCY INJECTION KIT
| Every Patient MUST Have |
|
Hydrocortisone injection kit (100 mg)
|
|
Syringes and needles
|
|
Instructions for self-injection / Family injection
|
|
Train patient AND family on IM injection
|
Self-Injection Technique
| Step | Action |
| 1 | Reconstitute hydrocortisone (if powder) |
| 2 | Draw up 100 mg |
| 3 | Inject into outer thigh (IM) |
| 4 |
Call for emergency help
|
| 5 | Lie down; Do not drive |
8.4 MEDICAL IDENTIFICATION
| Every Patient MUST Have |
|
Medical alert bracelet or necklace
|
|
Emergency card in wallet
|
|
Phone ICE contact with diagnosis
|
Card Should State
| Information |
| ”I have ADRENAL INSUFFICIENCY“ |
| ”In emergency, I need HYDROCORTISONE 100 mg IV/IM immediately“ |
| ”Do NOT wait for blood tests“ |
| Emergency contact details |
| Doctor’s contact |
8.5 PATIENT EDUCATION CHECKLIST
| ✅ Every Patient Must Know |
|
Never stop steroids suddenly
|
|
Double dose if unwell
|
|
Triple dose if moderately ill
|
|
Use injection if vomiting / Can’t take oral
|
|
Seek medical help if not improving
|
|
Always carry emergency injection
|
|
Wear medical alert identification
|
|
Inform all healthcare providers
|
|
Carry steroid card
|
SECTION 9: DRUG DOSES – QUICK REFERENCE
9.1 ACUTE CRISIS MANAGEMENT
| Step | Drug | Dose |
|
1
|
💊 Hydrocortisone
|
100 mg IV bolus → 50-100 mg q6-8h OR 200 mg/24h infusion
|
|
2
|
💧 0.9% Normal Saline
|
1L in first hour → 4-6L in 24h
|
|
3
|
💊 Dextrose
|
D50 50 mL IV if hypoglycemic
|
|
4
|
Antibiotics
|
Empiric if infection suspected |
|
5
|
💊 Noradrenaline
|
0.05-0.1 μg/kg/min if refractory hypotension |
9.2 ALTERNATIVE GLUCOCORTICOIDS
| Drug | Dose | Notes |
|
Dexamethasone
|
4 mg IV q12h | No mineralocorticoid effect |
|
Methylprednisolone
|
40 mg IV q12h | Minimal mineralocorticoid effect |
|
Prednisolone
|
25 mg PO q6h | If IV unavailable |
9.3 MAINTENANCE THERAPY
| Drug | Dose |
|
💊 Hydrocortisone
|
15-25 mg/day in divided doses |
|
💊 Fludrocortisone (Primary AI only)
|
0.05-0.2 mg once daily |
9.4 SICK DAY DOSING
| Severity | Hydrocortisone Dose |
|
Mild illness
|
2× usual dose
|
|
Moderate illness
|
3× usual dose
|
|
Severe / Vomiting
|
100 mg IM/IV
|
9.5 SURGICAL STRESS DOSING
| Surgery | Pre-op | Intra/Post-op |
|
Minor
|
Double oral | Double × 24h |
|
Moderate
|
50 mg IV | Double × 24-48h |
|
Major
|
100 mg IV | 50-100 mg IV q8h → Taper |
SECTION 10: SPECIAL SITUATIONS
10.1 ADRENAL CRISIS IN PREGNANCY
Key Points
| Consideration |
| Adrenal crisis can occur in pregnancy |
| Diagnosis can be challenging (Physiological changes mimic some features) |
|
Hydrocortisone is SAFE in pregnancy
|
|
Fludrocortisone is SAFE in pregnancy
|
| May need higher maintenance doses in 3rd trimester |
|
Labor/Delivery: Stress dose hydrocortisone required
|
Labor and Delivery Protocol
| Phase | Dose |
|
Early labor
|
Hydrocortisone 25-50 mg IV |
|
Active labor
|
Hydrocortisone 100 mg IV |
|
Delivery
|
Continue 50-100 mg IV q6-8h |
|
Post-delivery
|
Taper over 24-72 hours |
10.2 ADRENAL CRISIS IN CHILDREN
Key Points
| Consideration |
|
Hypoglycemia more common in children
|
| Weight-based dosing required |
| CAH is common cause in infants |
| Family education critical |
Pediatric Dosing
| Drug | Dose |
|
Hydrocortisone
|
50-100 mg/m² IV bolus (or 2-4 mg/kg, max 100 mg)
|
|
Maintenance
|
50-100 mg/m²/day IV in divided doses
|
|
Fluids
|
20 mL/kg NS bolus → Maintenance
|
|
Dextrose
|
2-4 mL/kg of D25 if hypoglycemic
|
10.3 ADRENAL CRISIS IN PATIENTS ON ANTICOAGULANTS
Suspect Adrenal Hemorrhage
| Clues |
| Patient on warfarin/heparin/DOACs |
| Sudden onset of: Abdominal/Flank pain, Hypotension, Fever |
| Falling hematocrit |
| CT: Bilateral adrenal hemorrhage |
Management
| Action |
|
Treat crisis standard protocol (Hydrocortisone + Fluids)
|
|
Reverse anticoagulation if severe bleeding
|
|
CT Adrenals to confirm
|
|
Will likely need lifelong steroid replacement
|
10.4 BILATERAL ADRENALECTOMY
Key Points
| Consideration |
| 100% dependent on exogenous steroids |
| High risk of crisis |
|
MUST have emergency injection kit
|
| Education critical |
10.5 SECONDARY ADRENAL INSUFFICIENCY
Key Differences
| Feature | Primary AI | Secondary AI |
|
Aldosterone
|
↓ | Normal |
|
Hyperkalemia
|
Yes | No |
|
Hyperpigmentation
|
Yes | No |
|
Fludrocortisone needed
|
Yes |
No
|
Management
| Same as primary EXCEPT: |
|
No fludrocortisone needed (aldosterone intact)
|
| Usually less severe hyponatremia |
| Consider other pituitary hormone deficiencies |
10.6 STEROID WITHDRAWAL CRISIS
Scenario
| Features |
| Patient on chronic steroids (> 3 weeks) |
| Abruptly stops or rapidly tapers steroids |
| Develops fatigue, Hypotension, Nausea |
Management
| Action |
|
Same treatment as adrenal crisis
|
| Restart steroids |
| Slow, gradual taper when stable |
| May take months for HPA axis to recover |
SECTION 11: 🇮🇳 INDIA-SPECIFIC CONSIDERATIONS
11.1 COMMON CAUSES IN INDIA
| Cause | Notes |
|
Tuberculosis
|
Most common cause of primary AI in India
|
|
Autoimmune
|
Increasing, especially urban areas |
|
Chronic steroid use
|
Common; Often over-the-counter; Hidden in Ayurvedic preparations |
|
Post-TB
|
May have adrenal calcification |
11.2 DRUG AVAILABILITY
| Drug | Availability | Cost |
|
Hydrocortisone injection 100 mg
|
✅ Widely available | ₹30-100 |
|
Hydrocortisone oral 10/20 mg
|
✅ Available | ₹50-150/month |
|
Fludrocortisone 0.1 mg
|
⚠️ Variable availability | ₹200-400/month |
|
Dexamethasone injection
|
✅ Widely available | ₹10-50 |
|
Normal Saline
|
✅ Widely available | ₹30-50/L |
11.3 PRACTICAL CHALLENGES
| Challenge | Solution |
|
Fludrocortisone availability
|
Patients should maintain adequate supply; Alternative suppliers |
|
Non-compliance
|
Education; Family involvement; Regular follow-up |
|
Hidden steroids in Ayurvedic preparations
|
Detailed medication history; Educate patients |
|
Delayed presentation
|
Community awareness; Primary care education |
|
Cost of long-term therapy
|
Generic options; Government schemes |
11.4 TB-RELATED ADRENAL INSUFFICIENCY
Features
| Findings |
| Most common cause in India |
| May have history of TB or TB contact |
| CT may show: Enlarged adrenals (acute) or Calcified adrenals (chronic) |
| May need ATT if active TB |
Management
| Action |
| Standard crisis management |
|
Start ATT if active TB
|
|
⚠️ Rifampicin increases cortisol metabolism – May need higher hydrocortisone doses during ATT (increase by 50-100%)
|
| Adrenal function rarely recovers – Usually lifelong replacement needed |
SECTION 12: SUMMARY TABLES
12.1 DIAGNOSTIC CLUES
| Finding | Suggests |
| Hypotension + Hyponatremia + Hyperkalemia | PRIMARY AI |
| Hypotension + Hyponatremia (without hyperkalemia) | SECONDARY AI |
| Hyperpigmentation | PRIMARY AI |
| Hypoglycemia + Hypotension | Adrenal crisis |
| Refractory shock | Think adrenal crisis |
12.2 IMMEDIATE MANAGEMENT CHECKLIST
| ✅ Action | Done |
|
Hydrocortisone 100 mg IV bolus
|
☐ |
|
IV access × 2 large bore
|
☐ |
|
0.9% NS 1L rapid infusion
|
☐ |
|
Check glucose – Treat if low
|
☐ |
|
Blood samples: Cortisol, ACTH, U&E, Glucose, Cultures
|
☐ |
|
ECG (Hyperkalemia)
|
☐ |
|
Search for precipitant
|
☐ |
|
Continuous monitoring
|
☐ |
12.3 TREATMENT PROTOCOL SUMMARY
| Step | Intervention | Dose/Details |
|
1
|
Hydrocortisone IV | 100 mg bolus → 50-100 mg q6-8h |
|
2
|
IV Fluids | NS 1L/hr × 1h → 4-6L/24h |
|
3
|
Dextrose | If hypoglycemic |
|
4
|
Treat precipitant | Antibiotics if infection |
|
5
|
Monitor | BP, HR, UO, Glucose, Electrolytes |
|
6
|
Taper when stable | → Oral maintenance over 3-5 days |
12.4 SICK DAY RULES SUMMARY
| Illness Severity | Action |
|
Mild
|
Double oral dose |
|
Moderate
|
Triple oral dose |
|
Severe / Vomiting
|
100 mg IM/IV + Seek help |
12.5 PATIENT ESSENTIALS CHECKLIST
| ✅ Every Patient Must Have |
| Emergency hydrocortisone kit |
| Training on self-injection |
| Medical alert ID |
| Steroid card |
| Written sick day rules |
| Emergency contact numbers |
| Regular follow-up |
12.6 PRIMARY VS SECONDARY AI COMPARISON
| Feature | Primary AI | Secondary AI |
|
Site
|
Adrenal | Pituitary/Hypothalamus |
|
ACTH
|
↑↑ | ↓/Normal |
|
Aldosterone
|
↓ | Normal |
|
Hyperkalemia
|
Yes | No |
|
Hyperpigmentation
|
Yes | No |
|
Fludrocortisone
|
Needed | Not needed |
|
Salt craving
|
Yes | No |
📚 ABBREVIATIONS
| Abbreviation | Full Form |
| ACTH | Adrenocorticotropic Hormone |
| AI | Adrenal Insufficiency |
| ATT | Antitubercular Therapy |
| BP | Blood Pressure |
| CAH | Congenital Adrenal Hyperplasia |
| CMV | Cytomegalovirus |
| CT | Computed Tomography |
| D25/D50 | 25%/50% Dextrose |
| DIC | Disseminated Intravascular Coagulation |
| DOAC | Direct Oral Anticoagulant |
| ECG | Electrocardiogram |
| GI | Gastrointestinal |
| HIV | Human Immunodeficiency Virus |
| HPA | Hypothalamic-Pituitary-Adrenal |
| HR | Heart Rate |
| ICE | In Case of Emergency |
| ICU | Intensive Care Unit |
| IM | Intramuscular |
| IV | Intravenous |
| MAP | Mean Arterial Pressure |
| MRI | Magnetic Resonance Imaging |
| NS | Normal Saline |
| PO | Per Oral |
| RA | Rheumatoid Arthritis |
| SBP | Systolic Blood Pressure |
| TB | Tuberculosis |
| U&E | Urea and Electrolytes |
| UO | Urine Output |
| UTI | Urinary Tract Infection |
📖 KEY REFERENCES
| Source |
| Bornstein SR et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. JCEM 2016 |
| Puar TH et al. Adrenal Crisis: Still a Deadly Event in the 21st Century. Am J Med 2016 |
| Rushworth RL et al. Adrenal Crisis. NEJM 2019 |
| Husebye ES et al. Adrenal Insufficiency. Lancet 2021 |
| Bancos I et al. Diagnosis and Management of Adrenal Insufficiency. Lancet Diabetes Endocrinol 2015 |
| Hahner S et al. High Incidence of Adrenal Crisis in Educated Patients with Chronic Adrenal Insufficiency. JCEM 2015 |
| Harrison’s Principles of Internal Medicine, 21st Edition |
| Williams Textbook of Endocrinology, 14th Edition |
Document Version: 1.0
Last Updated: December 2025
For: Healthcare Professionals Only
Related Guidelines: Addison’s Disease (Primary Adrenal Insufficiency); Cushing’s Syndrome
Key Points:
-
- 🚨 TREAT FIRST – Do NOT wait for labs
- 💊 Hydrocortisone 100 mg IV immediately
- 💧 Aggressive IV Normal Saline
- 🔍 Search for and treat precipitant
- 📋 Patient education and emergency kit are ESSENTIAL for prevention
End of Guideline
🛡️
Medical Advisory
Clinical guidelines are subject to change. Physicians should exercise their regular clinical judgment. This protocol does not replace individual institutional policies. Verified for Q1 2026.
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