Intended for healthcare professionals


How to avoid precipitating an acute adrenal crisis

BMJ 2012; 345 doi: (Published 09 October 2012) Cite this as: BMJ 2012;345:e6333
  1. John A H Wass, professor of endocrinology1,
  2. Wiebke Arlt, professor of medicine2
  1. 1Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism, Churchill Hospital, Oxford OX3 7LJ, UK
  2. 2Centre for Endocrinology, Diabetes and Metabolism (CEDAM), School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
  1. john.wass{at}

Most importantly, heed patients’ requests for hydrocortisone

There are two hormone deficiency syndromes that are rapidly fatal if untreated but which are quite easily managed. One is type 1 diabetes mellitus, commonly known to be treatable with insulin. The other is acute adrenocortical insufficiency (adrenal or so called addisonian crisis), which requires treatment with hydrocortisone. Unfortunately, too often, healthcare workers do not realise the urgency of treatment for acute adrenal crisis or fail to heed the requests of well informed patients for hydrocortisone.

Patients with adrenal insufficiency are at risk of developing life threatening adrenal crisis if steroids are reduced or stopped, or if glucocorticoid treatment is not increased during periods of increased stress (for example, illness, trauma, or surgery). The features of acute adrenal crisis include hypotension (particularly postural hypotension), shock, and hyponatraemia in 90% of patients. Hyperkalaemia is also a feature in 65% of patients. Fatal but avoidable addisonian crisis is the second most common cause of death in patients with known Addison’s disease, accounting for 15% of deaths in patients with this disease.1 2 Early treatment with parenteral hydrocortisone and intravenous rehydration with fluids are essential measures to avoid mortality. Why is this not always achieved?

The Addison’s Disease Self Help Group (, a charity that informs and supports patients with Addison’s disease, has …

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