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.[38]

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 local protocols 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.[38]

Intravenous fluids in the form of normal saline infusion 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 local protocols for a suitable corticosteroid taper regimen in a patient treated for adrenal crisis.

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 need only 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 anaesthesia) should be instructed to double their chronic maintenance dose of corticosteroid on the day of the procedure or for the duration of illness.[1]

The patient returns 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 anaesthesia; critical illness requiring ventilation; major trauma; active phase of labour and delivery) require parenteral corticosteroid (usually hydrocortisone).[1][51]

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 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 prednisolone 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 physiological). 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

prednisolone: 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 <3-4 weeks
1st line – 

corticosteroid discontinuation

Tapering the corticosteroid dose is unnecessary and treatment can be discontinued, regardless of the dose.

In discontinuing 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 >3-4 weeks
1st line – 

corticosteroid taper

When the corticosteroid dose is >40 mg/day (prednisolone equivalent), a decrement of 5-10 mg/day every week is recommended.[37]​

When the dose is <40 mg/day (prednisolone equivalent), smaller decrements are recommended: corticosteroid dose 20-40 mg/day, 5 mg/day decrement every week; corticosteroid dose 10-20 mg/day, 2.5 mg/day decrement every 1 to 4 weeks; corticosteroid dose <10 mg/day, 1 mg/day decrement every 1 to 4 weeks.[37]

Note that tapering of long-term glucocorticoid therapy should only be attempted if the underlying disease for which the glucocorticoid was prescribed is controlled, and glucocorticoids are no longer required.[37] In these cases, glucocorticoids are tapered until approaching the physiological daily dose equivalent is achieved (e.g., 4-6 mg/day prednisolone).

Corticosteroid doses can be rapidly reduced to physiological replacement equivalents without fear of adrenal insufficiency. This corresponds to a prednisolone 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 physiological 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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