27th May 2025

Management

In acute adrenal crisis, the mainstay of treatment includes:

• IV hydrocortisone, typically given as 100 mg STAT followed by an infusion of 200 mg/24 hours. N.B. if co-existing hypothyroidism, thyroid hormones must not be replaced prior to glucocorticoids, as this can precipitate adrenal crisis.
• Fluid resuscitation with monitoring of blood pressure, fluid status and electrolytes.
• Correction of hypoglycaemia.
• Treatment of the underlying cause once stable.
• Education regarding symptoms and risk factors for adrenal crisis, issue of a steroid card or medical alert bracelet.

In intercurrent illness, those with PAI will require corticosteroid supplementation. In circumstances of severe stress or high risk of crisis (e.g. acute gastroenteritis, surgery, critical illness), IV hydrocortisone as described above is recommended. However, for minor stressors (e.g. febrile illness, minor procedures requiring fasting), doubling of the patient’s maintenance dose of corticosteroid is recommended.

For the management of PAI in stable patients, oral glucocorticoid (e.g. hydrocortisone or prednisolone) and mineralocorticoid (e.g. fludrocortisone) replacement therapy is given. This is titrated according to clinical symptoms until a maintenance dose is found. Mineralocorticoid dosing will be adjusted based on symptoms such as postural hypotension and salt-craving.