Clinical Pearls & Morning Reports
Published August 28, 2019
Adrenal crisis appears to be increasing in frequency, despite the availability of effective preventive strategies. Read the Review Article here.
Q: What is the definition of an adrenal crisis in an adult?
A: Given the lack of a research-based classification and in recognition of the physiological changes that distinguish an adrenal crisis from a milder episode of hypoadrenalism, pragmatic definitions of adrenal crisis have generally been adopted. An adrenal crisis in an adult is defined as an acute deterioration in health status associated with absolute hypotension (systolic blood pressure <100 mm Hg) or relative hypotension (systolic blood pressure ≥20 mm Hg lower than usual), with features that resolve within 1 to 2 hours after parenteral glucocorticoid administration (i.e., a marked resolution of hypotension within 1 hour and improvement in clinical symptoms over a period of 2 hours). Concomitant features in patients of all ages include acute abdominal symptoms; delirium, obtundation, or both; and hyponatremia, hyperkalemia, hypoglycemia, and pyrexia.
Q: What are some of the risk factors for adrenal crisis among patients with hypoadrenalism?
A: Susceptibility to adrenal crises varies among patients with hypoadrenalism. Risk factors include older age, a history of prior adrenal crises, the presence of autoimmune polyglandular syndromes, type 1 diabetes mellitus, and nonendocrine coexisting conditions such as asthma and cardiac disease. However, the mechanism of action of these various factors in adrenal crisis is unclear and may be specific to coexisting conditions. In addition, unknown factors may potentiate the risk of adrenal crisis, since some patients have numerous episodes, whereas others have few, if any, episodes.
A: Infections, which act as inflammatory stressors, commonly precipitate adrenal crises. Gastroenteritis is frequently cited as a precipitant and can be particularly hazardous, since vomiting and diarrhea impair the absorption of oral medication and may also exacerbate dehydration. Other pathophysiological states may precipitate an adrenal crisis if the body cannot mount an increase in endogenous cortisol and if the amount of replacement therapy is not increased. Such conditions include serious injury and major surgery, but situations that generally are associated with the need for milder cortisol increases (exercise and emotional upset) have been reported as crisis precipitants in up to 10% of episodes, according to the results of patient surveys in which no specific precipitant was identified. Adrenal crises have been reported in association with the release of acute-phase cytokines and other substances after certain relatively minor medical procedures such as vaccinations and zoledronic acid infusion. Some types of immunotherapy or chemotherapy may precipitate adrenal crises.
A: Key strategies that can prevent adrenal crisis include an individualized prescription and plan for the use of supplementary glucocorticoid administration for physiological stress; use of parenteral hydrocortisone, preferably at home, when oral glucocorticoids cannot be taken; and the provision of devices, such as a MedicAlert bracelet or necklace, that can warn caregivers of the risk of adrenal crisis when patients cannot communicate verbally. Patients and their family members should be taught how to perform intramuscular injection of hydrocortisone and should be provided with vials, needles, and syringes. Parenteral administration of hydrocortisone at home may prevent progression of an early adrenal crisis. However, injectable hydrocortisone is not offered to, or may not be obtained by, all patients. Barriers to hydrocortisone use by patients include reluctance to inject the drug intramuscularly, impaired dexterity, and advanced age. Subcutaneous administration of hydrocortisone is an alternative to the intramuscular route, and although this is an off-label method of administration, it may be more acceptable to patients.