Acute adrenal insufficiency, also termed adrenal crisis, is a life-threatening endocrine emergency brought about by a lack of production of the adrenal hormone cortisol, the major glucocorticoid. Identifying patients at risk and prompt management can save lives.
This guidance identifies the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures.
- A new NHS Steroid Emergency Card is being launched, to be carried by patients at risk of adrenal crisis.
- Patients taking exogenous steroids are also at risk of AI. Patients taking prednisolone 5 mg/day or equivalent for 4 weeks or longer across all routes of administration (oral, topical, inhaled or intranasal) should be issued with an NHS Steroid Emergency Card.
- Patients taking inhaled beclamethasone >1000 mcg/ day or fluticasone >500 mcg/day are at risk of adrenal insufficiency due to hypothalamo-pituitary axis suppression and should be issued with an NHS Steroid Emergency Card.
- Patients thought to be having an adrenal crisis should be treated promptly with 100 mg hydrocortisone by iv or im injection, followed by 200 mg hydrocortisone/24 h continuous iv infusion in glucose 5%/24 h, or 50 mg 6 hourly im (or iv) and intravenous fluid (sodium chloride 0.9%).
- Emergency treatment should not be delayed while waiting to confirm a diagnosis of adrenal insufficiency.
- All healthcare professionals should be aware of the patient groups at risk of an adrenal crisis.
- All doctors should be aware of the need to start steroids promptly in patients at risk of an adrenal crisis, either at replacement or stress doses, particularly when presenting in the emergency department or to acute medicine teams, undergoing surgery, or invasive procedures.
- Patient education is a key part of management. Patient resources are available on the Addison’s Disease Self Help Group (www.addisonsdisease.org.uk) and Pituitary Foundations’ websites (www.pituitary.org.uk).
NHS Steroid Emergency Card
The Royal College of Physicians has worked with the Society for Endocrinology and in conjunction with NHSE to develop the approved NHS Steroid Emergency Card.
This new card has been developed to be carried by patients at risk of adrenal crisis. The new emergency card will increase awareness of the need to increase steroids promptly in patients at risk of an adrenal crisis, particularly when presenting in the emergency department or to acute medicine teams, undergoing surgery, or invasive procedures.
The NHS Emergency Steroid Card is available to download as a PDF via the Society for Endocrinology website.