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Clinical practice

Adrenal Crisis Information

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.

Management of adrenal crisis summary

 

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. Patients taking exogenous glucocorticoids across any route (oral, intra-articular, intra-muscular, inhaled, nasal and topical preparations) being used to treat a variety of medical conditions, can cause adrenal insufficiency by suppressing the hypothalamo-pituitary-adrenal axis. The Society for Endocrinology has endorsed a joint guidance document written together with Specialist Pharmacy Services.

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.

Children can be given i.v. or i.m. hydrocortisone as follows:

  • Infants up to 1 year - 25mg
  • children 1 to 5 years - 50mg
  • children 6 to 12 years - 100mg

These doses can be repeated three or four times in 24 hours depending upon the condition being treated and the patient's response.

Download the BSPED Paediatric Steroid Treatment Card for full guidance.

The new card can be ordered through the usual NHS ordering mechanisms:

  • Secondary Care: Xerox online portal 
    You may need to raise a Non-Catalogue Requisition in Oracle, selecting supplier as XEROX, and we can process the requisition by raising the order with NHS Forms. Cost is £3.94 excluding VAT for 100 cards. 1 unit is 100 cards.
  • Primary Care: PCSE online portal 
  • Private sector: email: nhs.print@nhs.net for registration form

Patients can also download a pdf version if they wish. Some patients are also uploading the pdf version as the lock screen on their mobile phones, to show health care professionals in a medical emergency.

Read the guidance on the prevention and emergency management of adult patients with adrenal insufficiency that accompanies the NHS Steroid Emergency Card. 

Download the NHS Steroid Emergency Card

This card and its associated guidance is intended for use by adults (16+)

The BSPED Paediatric Steroid Treatment Card provides a succinct steroid management plan for illnesses, emergency injections and blood sugar & electrolyte correction. Please encourage your patients to download and use this card. BSPED is keen to encourage uniform practice and improve the care of children and young people with adrenal insufficiency. If you have any queries regarding the card please contact the BSPED Clinical Committee 

Summary guidance:

Give IV or IM hydrocortisone

  • Infants up to 1 year - 25mg
  • children 1 to 5 years -  50mg
  • children 6 to 12 years - 100mg

Download the BSPED Paediatric Steroid Treatment Card

 

The new NHS Steroid Emergency Card is a prompt to healthcare professionals when patients are admitted in crisis/as an emergency or when undergoing surgery/procedure, to ensure steroid treatment is given appropriately and promptly. The card clearly outlines first management steps in an emergency. In addition, the card contains a QR code that links to further specialist advice.

The blue Steroid Treatment Card and the London Respiratory Network Card are unaffected by the introduction of the NHS Steroid Emergency Card. Patients should keep these if advised by their medical team whilst implementation of the new steroid emergency card takes place.

 

All patients with adrenal insufficiency of any cause, or who are considered at risk of adrenal insufficiency, are at risk of adrenal crisis and should be given stress doses of exogenous glucocorticoids at times which would normally provoke a cortisol stress response (ie during surgery or labour, for invasive procedures, following trauma or when acutely unwell) as per the Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology to maintain as near physiological concentrations of cortisol as possible (Woodcock 2020, Prete 2020).

The Society for Endocrinology Steroid Emergency Card working group has suggested these sick day rules in line with most recent evidence of cortisol response to illness, and guidance for management of AI for patients with COVID-19 (Prete JCEM 2020, Arlt EJE 2020).

Download the Patient Information Sheet

Related links for patient information

Steroid replacement therapy Information for patients (University of Leeds) 

Hydrocortisone Sick Day Rules - The Pituitary Foundation

Keeping safe with adrenal insufficiency - The Pituitary Foundation

Newly Diagnosed - Sick Day Rules - Addison's Disease Self-Help Group

Dr Helen L Simpson, FRCP, PhD (Chair)
Consultant Endocrinologist
RCP Patient Safety Committee
Department of Diabetes and Endocrinology, UCLH NHS Foundation Trust

Dr Yasir Elhassan
Consultant Endocrinologist
Queen Elizabeth Hospital Birmingham and University of Birmingham

Dr Anna L Mitchell
Consultant endocrinologist
Newcastle upon Tyne Hospitals NHS Foundation Trust

Dr Michael O’Reilly
Consultant Endocrinologist Beaumont Hospital Dublin
Clinical Associate Professor Royal College of Surgeons in Ireland (RCSI)

Dr Robert D Murray
Consultant Endocrinologist & Honorary Associate Professor
Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust

Professor Jeremy Tomlinson
NIHR Oxford Biomedical Research Centre and University of Oxford

Professor John Wass
Professor of Endocrinology, Oxford University.
GIRFT lead for Endocrinology, NHS England

Dr Antonia Brooke FRCP, MD, MA
MacLeod Diabetes and Endocrine Centre
Royal Devon and Exeter Foundation Trust

Alessandro Prete, MD
Clinical Research Fellow in Endocrinology and Diabetes
Institute of Metabolism and Systems Research, University of Birmingham

Professor Aled Rees
Professor of Endocrinology and Consultant Endocrinologist
Neuroscience and Mental Health Research Institute
Cardiff University

Dr Claire Higham
Consultant Endocrinologist
Christie Hospital NHS Foundation Trust

Lisa Shepherd
Endocrinology ANP/NMP, NIHR Clinical Doctoral Research Fellow
Diabetes & Endocrinology, Birmingham Heartlands Hospital/Diabetes & Endocrine Centre

Louise Breen
Endocrine Specialist Nurse, Advanced Nurse Practitioner for Endocrinology
Guy’s and St Thomas’ NHS Foundation Trust

Miriam Asia
Senior Endocrine Clinical Nurse Specialist
University Hospitals Birmingham NHS Foundation Trust

Professor Wiebke Arlt MD DSc FRCP FMedSci
William Withering Chair of Medicine
Director, Institute of Metabolism and Systems Research (IMSR)
College of Medical and Dental Sciences, University of Birmingham

Professor Simon Pearce
Professor of Endocrinology
Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University

Professor Peter Clayton MD FRCPCH
Honorary Consultant Paediatrician, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust (MFT)
Professor of Paediatric Endocrinology, Division of Developmental Biology & Medicine, FBMH, UoM
Chief Academic Officer, Health Innovation Manchester
Clinical Director, Manchester Academic Health Science Centre
Deputy Vice-President & Deputy Dean, Faculty of Biology, Medicine & Health, University of Manchester

Colin Perry PhD FRCP (UK)
Consultant Endocrinologist
Associate Director of Medical Education
Honorary Associate Clinical Professor
Queen Elizabeth University Hospital, Glasgow

Download sick day rules

 

Download sick day rules figure

 

Contact adrenal@endocrinology.org for more information.