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Management of Adrenal Insufficiency

Introduction

The adrenal cortex is responsible for producing glucocorticoids, mineralocorticoids and androgens. When there is insufficiency it can either be primary (e.g. there is structural damage to the gland) or secondary (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. It complements the GGC guideline on Suspected Iatrogenic Adrenal Insufficiency, which describes the assessment of adrenal function in patients on glucocorticoid for a non-endocrine condition.

Assessment / monitoring

If patient has suspected acute adrenal insufficiency:

  • Diagnostic measures should never postpone treatment and if adrenal crisis is suspected, treatment should be initiated without delay.
  • Establish venous access and draw blood for U&Es, glucose, cortisol and ACTH (adrenocorticotropic hormone). See appendix 1 of the GGC guideline on Suspected Iatrogenic Adrenal Insufficiency.

 Then see General management and drug therapy section below.

General management and drug therapy

Acute adrenal insufficiency

  • Give hydrocortisone IV 100mg immediately then give 200mg over 24 hours either by continuous IV infusion or by 50mg IV 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

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). Take a paired ACTH sample at baseline.
  • 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.

Long-term use of corticosteroids - general advice

To prevent acute insufficiency in a patient on long-term steroids consider the following:

  • Patients on maintenance corticosteroids must be given steroid cover across any surgical procedure. See BNF for details.
  • Prior to surgical procedures involving a general anaesthetic – consult with the anaesthetist.
  • If considering cessation of long-term glucocorticoid, a gradual slow reduction will be needed. Consider performing a SST when down to prednisolone ≤5mg, hydrocortisone ≤20mg, or dexamethasone ≤0.5mg. On the morning of SST, omit the usual corticosteroid dose until test is completed (Note: hydrocortisone will be detected in the cortisol assay). Any queries should be directed to the local Endocrine Team.
    For patients with intercurrent illness e.g. infection:
  • Double the steroid dose
  • If unwell / unable to take oral therapy, change to hydrocortisone IV 200mg given over 24 hours either by continuous IV infusion or by 50mg IV every six hours
  • Seek advice on adjustment of corticosteroid doses. 

Other Information

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.

 

Guideline reviewed: December 2022

Page updated: March 2023