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PubMed This is a summary of 22 peer-reviewed journal articles Updated
Endocrinology · Adrenal Crisis

Preventing and Managing Adrenal Crisis

At a Glance

An adrenal crisis is a life-threatening medical emergency caused by dangerously low cortisol levels. To prevent a crisis during illness, patients must follow 'sick day rules' by increasing their hydrocortisone. If vomiting occurs, an emergency injection must be administered immediately.

An adrenal crisis (or Addisonian crisis) is a life-threatening medical emergency. It happens when your body’s levels of cortisol drop dangerously low, causing your blood pressure to crash and your vital organs to begin failing [1][2]. Because this can happen quickly, learning to recognize the warning signs and knowing exactly how to respond is your most important tool for staying safe [3][4].

Recognizing the Early Warning Signs

A crisis often starts with “prodromal” (early) symptoms. If you notice these, you must act immediately to prevent the situation from becoming life-threatening [5][6]:

  • Extreme, sudden weakness or profound fatigue [7].
  • Gastrointestinal distress: Nausea, repeated vomiting, or acute abdominal pain [8][9].
  • Mental changes: Confusion, dizziness, or feeling like you might faint [7][10].
  • Low blood pressure: Feeling lightheaded when you stand up [1].

“Sick Day Rules” and Stress Dosing

When your body is under physical stress—such as from a fever, infection, or injury—it naturally requires more cortisol than your daily maintenance dose provides. Following “sick day rules” helps bridge this gap [3][11].

Crucially, sick day rules generally only apply to your glucocorticoid (hydrocortisone). You typically do not increase your mineralocorticoid (fludrocortisone) unless specifically instructed by your doctor.

  • For Minor Illness/Fever: Doctors typically advise doubling or tripling your oral hydrocortisone dose until the illness passes [12][13].
  • For Major Stress (Surgery/Trauma): Major stressors require high doses of medication delivered by injection (intravenously or intramuscularly) because your body cannot absorb pills quickly enough during a crisis [14][15].
  • The “Vomiting Rule”: If you vomit within 45 minutes of taking your pill and cannot keep a replacement dose down, you are at immediate risk. You must use your emergency injection kit and seek medical help immediately [11][16].

Your Emergency Lifeline: The Injection Kit

Every person with Addison’s disease must carry an emergency injection kit at all times [11][17]. This kit typically contains:

  1. Injectable Hydrocortisone: Usually an “Act-O-Vial” (like Solu-Cortef) containing both powder and liquid that you must actively mix by pressing down before drawing it into the syringe [18].
  2. Syringe and Needle: For an intramuscular (IM) injection into a large muscle, like the outer thigh [11][17].

Your doctor or nurse will prescribe this and must provide hands-on training for you and your family on how to properly mix and inject it. Do not hesitate to ask for this training.

Advocating for Yourself in the ER

If you are in a crisis, you may arrive at an Emergency Room where the staff is unfamiliar with Addison’s disease. You or your caregiver must be prepared to advocate for the standard of care [9][8]:

  • State Clearly: “I have Addison’s disease and I am in adrenal crisis. I need an immediate injection of 100mg hydrocortisone.”
  • Fluid Resuscitation: You will likely need “isotonic saline” (IV fluids) to help raise your blood pressure. You should also ask for fluids “with dextrose” if your blood sugar is low, as hypoglycemia is common during a crisis [9][1].
  • Medical ID: Showing a medical alert bracelet or a steroid emergency card can help the ER team understand the urgency of your situation instantly. You can obtain a steroid emergency card from your endocrinologist or print one from patient organizations like the National Adrenal Diseases Foundation (NADF) or the Addison’s Disease Self-Help Group (ADSHG) [19][20].

By being prepared with an injection kit, a clear plan for sick days, and the knowledge of how to advocate for yourself, you can manage the risks of Addison’s disease and live with confidence [21][22].

Previous: Steroid Replacement Therapy: The Standard of Care | Next: Living with Addison’s: Long-Term Health and Well-being

Common questions in this guide

What are the early warning signs of an adrenal crisis?
Early warning signs include sudden extreme weakness, severe fatigue, nausea, vomiting, acute abdominal pain, confusion, and feeling dizzy or lightheaded when standing up. If you notice these symptoms, you must act quickly to prevent the situation from worsening.
What are sick day rules for Addison's disease?
Sick day rules involve increasing your daily oral hydrocortisone dose—usually by doubling or tripling it—when your body is under physical stress from an illness or fever. This extra medication provides the cortisol your body naturally needs to fight the stress.
When do I need to use my emergency hydrocortisone injection kit?
You should use your emergency injection kit if you experience major physical stress, like a severe injury, or if you vomit within 45 minutes of taking your oral medication and cannot keep a replacement pill down. Once you use the injection, seek immediate medical help.
What should I tell the emergency room staff if I suspect a crisis?
Tell the ER staff clearly that you have Addison's disease, are in adrenal crisis, and require an immediate injection of 100mg of hydrocortisone along with IV fluids. Showing them a medical alert bracelet or steroid emergency card can help convey the extreme urgency.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Can you provide me with an 'emergency letter' to show ER staff that explains my diagnosis and required crisis treatment?
  2. 2.At what specific temperature or severity of illness should I switch from doubling my dose to tripling it?
  3. 3.What is the maximum number of days I should follow 'sick day rules' before I must call your office?
  4. 4.When should I use the injection kit instead of just taking extra oral pills?
  5. 5.Can you or a nurse provide a hands-on training session for my family and me on how to mix and administer my emergency injection kit?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

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This page provides educational information on recognizing and managing an adrenal crisis. Always follow the specific emergency protocols, sick day rules, and injection training provided by your endocrinologist.

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