Adrenal Suppression and Adrenal Crisis: Emergency Recognition, Assessment and Management

Learning objectives

• Explain HPA-axis suppression, primary, secondary and tertiary adrenal insufficiency and the difference between withdrawal symptoms and adrenal crisis.
• Recognise chronic symptoms, acute red flags and the common triggers of crisis.
• Perform a rapid ABCDE assessment with glucose, electrolytes, ECG, shock and infection evaluation.
• Describe emergency hydrocortisone, isotonic fluid, dextrose, electrolyte and precipitant management.
• Teach steroid tapering, sick-day rules, emergency cards, injection skills and safe follow-up.

Cortisol and the HPA axis

Stress activates the hypothalamus to release corticotropin-releasing hormone (CRH), which stimulates pituitary ACTH. ACTH stimulates the adrenal cortex to produce cortisol. Cortisol maintains vascular responsiveness to catecholamines, supports glucose production, controls inflammation and helps the body tolerate infection, surgery and trauma. Cortisol secretion normally rises sharply during serious illness.

Exogenous glucocorticoids provide negative feedback, reducing CRH and ACTH. After prolonged suppression, the adrenal cortex becomes less responsive and may need weeks to months to recover. The 2024 ESE/Endocrine Society guideline considers oral exposure a risk when treatment lasts about 3–4 weeks or longer and the dose exceeds approximately 15–25 mg hydrocortisone equivalent daily (for example, 4–6 mg prednisone/prednisolone), although risk varies with route, timing, potency and individual susceptibility.

Types of adrenal insufficiency

Causes and risk settings

• Oral prednisolone, prednisone, dexamethasone or hydrocortisone for inflammatory disease, asthma, autoimmune disease, cancer or transplant care.
• Repeated intra-articular/epidural injections, potent topical steroids, high-dose inhaled steroids or steroid-containing traditional/beauty products.
• Recent rapid taper, missed doses, abrupt discontinuation, vomiting, malabsorption or inability to obtain medication.
• Critical illness: fever, sepsis, malaria, gastroenteritis, trauma, surgery, burns, childbirth, severe pain or prolonged fasting.
• Medicines that alter steroid metabolism, pituitary disease, adrenal haemorrhage, bilateral adrenalectomy or treatment of Cushing syndrome.

Chronic symptoms before crisis

• Persistent fatigue, weakness, reduced exercise tolerance, dizziness, weight loss, poor appetite, nausea or abdominal discomfort.
• Low blood pressure, postural symptoms, salt craving, dehydration, muscle/joint aches and recurrent unexplained hypoglycaemia.
• Hyponatraemia, hyperkalaemia, eosinophilia, anaemia or low glucose on previous laboratory tests.
• Hyperpigmentation of skin creases, scars, palmar lines or oral mucosa suggests primary disease; it may be absent in secondary/tertiary suppression.
• Glucocorticoid withdrawal syndrome can cause myalgia, arthralgia, lethargy, mood change and nausea even without dangerous cortisol deficiency; crisis must still be excluded during acute illness.

First contact and scene priorities

1. Use standard precautions and look for steroid packets, emergency cards, injection kits, medical-alert jewellery and recent discharge letters.
2. Call for emergency transport and senior support. Adrenal crisis is a medical emergency even if the patient has no confirmed diagnosis.
3. Ask the patient or relative: steroid name, route, dose, last dose, duration, recent taper, vomiting, illness, surgery, pregnancy and access barriers.
4. Position for shock while protecting the airway; use a lateral position if vomiting or reduced consciousness and no contraindication.
5. Do not delay emergency hydrocortisone for cortisol/ACTH results. If blood can be collected without delaying treatment, take it first.

ABCDE assessment

A — Airway

• Assess speech, secretions, vomiting and consciousness; hypoglycaemia, shock and electrolyte disturbance may impair airway protection.
• Suction and provide airway support as trained. Prepare for advanced management when GCS is falling.

B — Breathing

• Count respiratory rate, measure SpO₂ and look for sepsis, aspiration, pulmonary oedema and metabolic acidosis.
• Give oxygen for hypoxaemia or respiratory distress according to local protocol; do not mistake compensatory tachypnoea for a primary lung disease without assessment.

C — Circulation

• Check pulse, BP (including postural change when safe), capillary refill, temperature, peripheral perfusion and urine output.
• Establish IV/IO access in shock; obtain electrolytes, glucose, cortisol/ACTH, urea/creatinine, blood count, blood gas and cultures when feasible.
• Start isotonic saline rapidly for hypotension under the adrenal-crisis protocol and reassess lungs, perfusion and urine output.

D — Disability

• Record AVPU/GCS, pupils, confusion and seizures. Check bedside glucose immediately and repeat after dextrose.
• Severe hyponatraemia can cause headache, confusion and seizures; hyperkalaemia can cause weakness and fatal dysrhythmia.

E — Exposure

• Measure temperature, inspect for infection, wounds, hyperpigmentation, dehydration, abdominal tenderness, trauma and steroid injection sites.
• Preserve warmth and dignity; avoid unnecessary exposure in a shocked patient.

Focused history

Investigations

• Bedside glucose and repeat measurements; obtain venous/arterial blood gas and lactate in shock or severe illness.
• Serum sodium, potassium, bicarbonate, urea/creatinine, calcium, magnesium, full blood count and ECG for dysrhythmia/hyperkalaemia.
• Take serum cortisol and ACTH before hydrocortisone only if this causes no delay; a random cortisol may be difficult to interpret after exogenous steroid exposure.
• After stabilisation, endocrine testing may include morning cortisol, ACTH stimulation test, renin/aldosterone, antibodies and pituitary/adrenal imaging to determine the cause.
• Search for triggers with cultures, urinalysis, malaria testing where relevant, chest imaging, pregnancy testing and targeted tests for trauma, MI, PE or abdominal disease.

Immediate treatment of suspected adrenal crisis

1. Hydrocortisone: give 100 mg IV or IM immediately in adults under the emergency protocol. Do not wait for laboratory confirmation.
2. Fluids: rapidly rehydrate with 0.9% saline or an approved isotonic crystalloid, reassessing BP, lungs, urine output, sodium and heart/renal status.
3. Glucose: treat documented hypoglycaemia with IV dextrose or oral carbohydrate only when swallowing is safe; add dextrose to IV fluid when clinically indicated.
4. Continuation: hospital protocols commonly use hydrocortisone 200 mg over 24 hours by continuous infusion or 50 mg IV/IM every 6 hours after the initial dose.
5. Trigger: treat sepsis, gastroenteritis, trauma, bleeding, surgery, malaria, MI or other precipitant using the appropriate pathway.
6. Electrolytes: monitor and manage hyperkalaemia, hyponatraemia, acidosis and renal impairment with senior/critical-care support.

Hospital management and transition

• Admit to a monitored area until BP, electrolytes, glucose, mental state and the precipitating illness are stable.
• Continue parenteral hydrocortisone while vomiting, hypotension or severe illness persists; switch to oral replacement only when the patient is stable and absorbing reliably.
• Adjust fluids for heart failure, kidney failure, older age and ongoing losses. Monitor for pulmonary oedema and rapid sodium correction.
• Consult endocrinology to establish whether suppression is primary, secondary or tertiary and to plan tapering, replacement and testing of recovery.
• Never stop the only source of glucocorticoid abruptly. Taper only when the underlying disease is controlled and the prescriber/endocrine team directs it.

Tapering and assessing recovery

Nursing and EMT care

• Trend BP, pulse, mental state, temperature, capillary glucose, sodium, potassium, fluid balance and urine output.
• Check IV/IM hydrocortisone dose, time, route and response; use an independent check where policy requires.
• Maintain aspiration, falls and seizure precautions; provide oral care and safe repositioning.
• Inspect IV sites, monitor fluid response and report crackles, increasing oxygen need, oedema or absent urine.
• Use SBAR to hand over last steroid dose, time of hydrocortisone, glucose/potassium values, suspected trigger and response to fluids.
• Teach the patient and family with teach-back: daily replacement, sick-day rules, injection practice, card/bracelet and emergency contact.

Prevention and steroid safety

• Carry a steroid emergency card or medical-alert identification and keep an emergency hydrocortisone injection available when prescribed.
• Never stop long-term steroids suddenly, miss doses during illness or assume inhaled/topical/injected steroids are risk-free.
• During vomiting, diarrhoea or severe illness, follow the written sick-day plan and seek help if oral medication cannot be absorbed.
• Tell every clinician, dentist, midwife and emergency responder about steroid dependence before procedures or surgery.
• Keep a reserve supply, check expiry and storage, and ensure family/co-workers know when and how to give emergency injection.
• Review bone health, infection prevention, blood pressure, glucose and eye care during long-term glucocorticoid treatment.

Clinical scenarios

Common errors to avoid

• Waiting for cortisol/ACTH results before giving hydrocortisone in suspected crisis.
• Stopping chronic steroids abruptly or failing to stress-dose during major illness, surgery, trauma or labour.
• Missing adrenal suppression because the steroid is inhaled, topical, injected or obtained outside the formal prescription list.
• Treating hypotension with fluids alone while ignoring cortisol deficiency, hypoglycaemia, hyperkalaemia or sepsis.
• Giving large fluid volumes without reassessing lungs, renal function, sodium and urine output.
• Discharging without an emergency card, injection plan, supply check and clear follow-up.

Revision questions

1. Explain how long-term glucocorticoids suppress the HPA axis.
2. What treatment exposure and duration commonly place an adult at risk of adrenal suppression?
3. List six symptoms/signs of adrenal crisis and four common precipitants.
4. Why should hydrocortisone not be delayed for cortisol or ACTH results?
5. Describe the emergency sequence for a patient with shock and hypoglycaemia after steroid withdrawal.
6. What education and equipment should a steroid-dependent patient have before discharge?

Key takeaways

References for further study

• European Society of Endocrinology/Endocrine Society. Glucocorticoid-Induced Adrenal Insufficiency Guideline, 2024.
• Society for Endocrinology. Adrenal Crisis Information — immediate hydrocortisone and fluid guidance.
• NICE. Adrenal insufficiency: identification and management, 2024.
• NIDDK. Treatment for Adrenal Insufficiency and Addison’s Disease.
• Follow current Uganda Ministry of Health, hospital and endocrine protocols for adult, paediatric, pregnancy and perioperative stress-dose care.