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Clinical practice

Adrenal Crisis Information

Our Clinical Committee have issued an advice statement with a summary to help keep adrenal insufficiency patients safe during the COVID-19 (Coronavirus) crisis.

Read advice statement

 

Read summary advice

 

Diagnostic measures should never delay treatment and if adrenal crisis is suspected, treatment should be initiated WITHOUT DELAY.

Short-term administration of high doses of glucocorticoids is never harmful but failure to treat adrenal crisis can result in the death of the patient.

Sick Day Rules

 

Management of adrenal crisis summary

 

If you suspect established or developing adrenal crisis in a patient:

Please immediately inject 100mg hydrocortisone i.v. or i.m. followed by rapid rehydration with i.v. administration of 0.9% saline solution (or equivalent).

Please maintain the patient on hydrocortisone at a dose of 200mg hydrocortisone per 24 hours (preferably by continuous i.v. infusion, alternatively by i.v. or i.m. injection of 50mg hydrocortisone every 6 hours) until clinical recovery and further guidance by an endocrinologist.

Adrenal crisis can be a manifestation of previously undiagnosed adrenal failure.

Adrenal crisis can also occur in patients with known adrenal insufficiency if existing cortisol replacement does not meet the increased need for cortisol, e.g. due to illness with fever, persistent vomiting or diarrhoea, trauma or childbirth. Preparation for invasive diagnostic procedures such as colonoscopy and surgery requiring general anaesthesia are further risk factors for adrenal crises.

To prevent adrenal crisis in all these situations, hydrocortisone needs to be administered and maintained as per above.

Do not hesitate to give high doses of hydrocortisone to a pregnant woman; hydrocortisone is inactivated in the placenta and does NOT affect the unborn baby. However, failure to treat a pregnant woman with adrenal insufficiency can result in death of mother and/or loss of the child.

In children, the initial hydrocortisone emergency injection should be given at a dose of 50mg/m2 body surface, followed by appropriate fluid resuscitation and 50 mg/m2/24h in infants and toddlers and 100 mg/m2/24h for school age children.

The SfE, RCP and NHSE/NHSI have been writing guidance to be released with a new NHS Emergency Steroid Card. To keep patients with adrenal insufficiency safe at this time, NHSE&I have agreed it is appropriate to release the card as a PDF that patients can download themselves.

Download NHS Emergency Steroid Card

 

Whilst this card and its associated guidance is primarily for the management of adults (16+), the full RCP guidance will include specific details on management of AI in children.

Dosing guidance for children from the EMC (which reflects UK MHRA and EMA information) is as follows:

"Systemic therapy in children: As a guide, infants up to 1 year may be given 25mg hydrocortisone intravenously; children 1 to 5 years, 50mg; 6 to 12 years, 100mg (1ml). This dose can be repeated three or four times in 24 hours depending upon the condition being treated and the patient's response."

An update on categorising patients with adrenal insufficiency as a vulnerable group will follow shortly.

For information and support in the interim please visit:

Pituitary Foundation: https://www.pituitary.org.uk/
Addison Support Group: www.addisonsdisease.org.uk