Management of Adrenal Insufficiency
The adrenal cortex is responsible for producing glucocorticoids, mineralocorticoids and androgens. When there is insufficiency it can either be primary related (e.g. there is structural damage to the gland) or secondary related (e.g. suppression of hypothalamic-pituitary axis by various factors).
This guideline advises on the general management of adrenal insufficiency in an acute situation and the diagnosis of it in the non-acute.
Assessment / monitoring
If patient has suspected acute adrenal insufficiency:
- Establish venous access and draw blood for electrolytes, glucose, cortisol and ACTH. Then see General management and drug therapy section below.
To diagnose adrenal insufficiency:
- In stable patients in whom hypothalamic-pituitary-adrenal failure is suspected, perform a short Synacthen® (Tetracosactide acetate, ACTH) test (SST):
- Synacthen® 250 micrograms IM or IV
- Sample cortisol at baseline and 30 minutes after Synacthen® (if unsure how to interpret results, seek specialist endocrine advice).
Then see General management and drug therapy section below.
General management and drug therapy
Acute adrenal insufficiency
- Give hydrocortisone IV 100mg immediately then every six hours.
- Fluid resuscitate with 0.9% sodium chloride. Continue IV fluids for the next 24–48 hours, depending on the severity of illness and co-morbidity.
- If hypoglycaemic (blood glucose value <4mmol/L) see under 'severe hypoglycaemia' for guidance.
- Once patient is stable and eating / drinking convert patient over to an oral glucocorticoid. If the precipitating illness is resolving, then reduce the maintenance dose over 72 hours e.g. Convert IV hydrocortisone dose to oral 50mg twice daily then over 72 hours reduce to 15–20mg orally at 8am and 5–10mg orally at 5pm.
Adrenal insufficiency – non acute situation
- Contact the Endocrine Team to arrange education, a Medic information bracelet and an emergency information card.
- Additional fludrocortisone is likely to be required in primary hypoadrenalism.
General advice on long-term use of corticosteroids
To prevent acute insufficiency in a patient on long-term steroids with an intercurrent illness, e.g. infection then:
- Double the steroid dose.
- If unwell / unable to take oral therapy, change to hydrocortisone IV 100mg three to four times daily.
- Patients on maintenance corticosteroids must be given steroid cover across any surgical procedure. See BNF for details.
- Surgical procedures involving a general anaesthetic – consult with the anaesthetist.
- Seek advice on adjustment of corticosteroid doses for patients with acute or severe intercurrent illness.
- If considering cessation of long-term glucocorticoid, a gradual slow reduction will be needed. Consider SST when down to prednisolone ≤5mg, hydrocortisone ≤20mg, or dexamethasone ≤0.5mg. on the morning of SST omit steroid dose until test is completed (Note: hydrocortisone will be detected in the cortisol assay). Any queries should be directed to the local Endocrine Team.
Corticosteroid dose equivalences
Prednisolone 5mg is approximately equivalent to:
- Hydrocortisone 20mg
- Dexamethasone 750micrograms
- Methylprednisolone 4mg
N.B. An equivalent dose is not always appropriate. When converting between different corticosteroids consider whether a dose increase (e.g. to cover intercurrent illness, as above) or a dose decrease (when tapering dose down) is appropriate.