Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

features of adrenal crisis

1st line – parenteral hydrocortisone

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INITIAL
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features of adrenal crisis
1st line – 

parenteral hydrocortisone

Patients with a history compatible with adrenal suppression and presenting with features of adrenal crisis (hypotension, circulatory failure) should be treated urgently with hydrocortisone.[32]

If improvement has occurred within 24 hours, which is common, the hydrocortisone dose can be decreased.

Patients can be switched to an oral dosing regimen once they are stable. Consult your local guidelines for a suitable corticosteroid taper regimen.

Primary options

hydrocortisone sodium succinate: 100 mg intravenously/intramuscularly as a single dose, followed by 200 mg per 24 hours as a continuous infusion (or 50 mg intravenously/intramuscularly every 6 hours), taper dose according to response as patient becomes stable

Plus – supportive measures

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INITIAL
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features of adrenal crisis
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Patients with a history compatible with adrenal suppression and presenting with features of adrenal crisis (i.e., hypotension, circulatory failure) should be treated urgently.[32]

Intravenous fluids in the form of 5% dextrose in normal saline should be given to address the volume depletion that is often present.

Plus – treatment of any precipitating event

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INITIAL
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features of adrenal crisis
Plus – 

treatment of any precipitating event

Treatment recommended for ALL patients in selected patient group

A search for the condition that precipitated the crisis, such as infection, should be undertaken. Treatment of the underlying cause should be instituted.

Plus – oral corticosteroid taper when stable

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INITIAL
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features of adrenal crisis
Plus – 

oral corticosteroid taper when stable

Treatment recommended for ALL patients in selected patient group

Consult your local protocols for a suitable taper regimen. An example would be to decrease the dose by one third to one half the dose daily until a maintenance dose of 20 mg in the morning and 10 mg in the afternoon or at night is attained. Some patients may only need a dose of 20 mg/day total (i.e., 20 mg every morning, or 15 mg in the morning and 5 mg in the afternoon or at night).

Primary options

hydrocortisone: consult specialist for guidance on dose

ACUTE

minor intercurrent stress

1st line – temporary double dose of existing corticosteroid

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ACUTE
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minor intercurrent stress
1st line – 

temporary double dose of existing corticosteroid

Patients experiencing minor intercurrent stress (e.g., febrile illness; minor procedure/surgery not requiring fasting such as tooth extraction or procedures that require local anesthesia) should be instructed to double their chronic maintenance dose of corticosteroid on the day of the procedure or for the duration of illness.[1] They then return to the usual dose when the stress resolves.

severe intercurrent stress

1st line – intravenous hydrocortisone (stress dose)

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ACUTE
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severe intercurrent stress
1st line – 

intravenous hydrocortisone (stress dose)

Patients who undergo severe stress situations (e.g., unable to take oral glucocorticoid, such as acute gastroenteritis or prolonged fasting for colonoscopy; surgery under general or regional anesthesia; critical illness requiring ventilation; major trauma; active phase of labor and delivery) require parenteral corticosteroid (usually hydrocortisone).[1][57]

Primary options

hydrocortisone sodium succinate: 100 mg intravenously/intramuscularly as a single dose, followed by 200 mg per 24 hours as a continuous infusion (or 50 mg intravenously/intramuscularly every 6 hours), taper dose according to response as patient becomes stable

Plus – oral corticosteroid taper when stable

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ACUTE
|
severe intercurrent stress
Plus – 

oral corticosteroid taper when stable

Treatment recommended for ALL patients in selected patient group

If patients are out of the critical phase of illness in less than 1 week but remain ill, then the dose of the corticosteroid can be tapered, using an oral formulation, back to previous pre-illness doses.

Consult your local protocols for a suitable taper regimen. An example of a taper until the previous pre-illness dose is reached would be decreasing from hydrocortisone 100 mg orally three times daily (equivalent to prednisone 25 mg three times daily), down to 75 mg twice daily for 1 to 2 days, then 50 mg twice daily for 1 to 2 days, then 25 mg twice daily for 1 to 2 days, then 20 mg in the morning and 10 mg in the afternoon for 1 month (a dose that most consider being physiologic). The taper can be stopped sooner (i.e., at a higher dose) if the pre-illness dose is already achieved.

Primary options

hydrocortisone: consult specialist for guidance on dose

OR

prednisone: consult specialist for guidance on dose

ONGOING

stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper

1st line – corticosteroid discontinuation

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ONGOING
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stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
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duration of corticosteroids <1 week
1st line – 

corticosteroid discontinuation

Can stop regardless of dose.

In discontinuing corticosteroid therapy, the underlying disease state may become reactivated, limiting reductions in corticosteroid dose.

1st line – corticosteroid discontinuation or taper

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ONGOING
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stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
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duration of corticosteroids 1 to 3 weeks
1st line – 

corticosteroid discontinuation or taper

Controversial with regard to need to taper. This depends on dose and the patient's general health/constitution.

Consider tapering if the dose is greater than the equivalent of prednisone 7.5 mg/day or hydrocortisone 30 mg/day.

In tapering and discontinuation of corticosteroid therapy, the underlying disease state may become reactivated, limiting reductions in corticosteroid dose.

1st line – corticosteroid taper

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ONGOING
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stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
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duration of corticosteroids >3 weeks
1st line – 

corticosteroid taper

Taper hydrocortisone by 10 mg (equivalent to prednisone 2.5 mg) every 3 to 4 days down to physiologic dose, then a more gradual reduction of hydrocortisone 2.5 mg every 2 to 4 weeks should be considered. It has been suggested that a morning cortisol level or a stimulation test should be checked once the dose is at an equivalent of hydrocortisone 10 mg/day, with discontinuation of corticosteroids if the cortisol level is normal.[58][59] The corticosteroid can also be discontinued if a stimulation test performed at any point during the physiologically dosed portion of the taper reveals normal cortisol levels. If patients develop signs and symptoms of adrenal insufficiency at any time, the dose decrement can be reduced.

So long as supraphysiologic corticosteroids continue, evaluation of adrenal function is not helpful.

Corticosteroid doses can be rapidly reduced to physiologic replacement equivalents without fear of adrenal insufficiency. This corresponds to a prednisone dose of 5 to 7.5 mg/day or its equivalent. However, in tapering and discontinuation of corticosteroid therapy, the underlying disease state may become reactivated, or patients may experience glucocorticoid withdrawal syndrome, limiting reductions in corticosteroid dose.

Once physiologic replacement levels are reached, tapering should continue at a slower rate. At this point, many physicians prefer to switch to a product with a short half-life, such as hydrocortisone, because the fluctuating serum levels allow for greater hypothalamic-pituitary-adrenal axis stimulation and recovery.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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