Stress Doses of Glucocorticoids Cannot Prevent Progression of All Adrenal Crises

Abstract

Adrenal crises (ACs) sometimes progress rapidly and can be fatal. The aims of the present study were to reveal whether stress doses of glucocorticoids (SDGs) can prevent progression of severe ACs and to suggest a method of prevention, through analysis of its clinical features. We studied 24 severe ACs (nine patients) that occurred after diagnosis of primary or secondary adrenal insufficiency, retrospectively. The following information was analyzed: 1) whether SDGs were given orally and/or sc; 2) duration from the time when some symptoms started to the time when the patient came to the hospital; and 3) presence of hypoglycemia and electrolyte disturbance (hyponatremia, hyperkalemia). Eleven crises occurred after taking SDGs. Ten crises progressed within 3 h. Six of these ten crises progressed to severe ACs despite the fact that the patients took SDGs. Six crises were observed in association with hypoglycemia, and five of these six crises occurred in patients under 5 yr of age. Three of the six crises in association with hypoglycemia progressed to ACs within 3 h. Two of the three crises progressed to severe status within 3 h despite the fact that the patients took SDGs. Electrolyte disturbance was observed in only one crisis. In conclusion, SDGs cannot prevent progression of all ACs. Progression can be associated with hypoglycemia, particularly in patients under 5 yr of age. Patients should be given guidance on an ongoing basis on how to prevent ACs and hypoglycemia.

Incidence and Characteristics of Adrenal Crisis in Children Younger than 7 Years with 21-Hydroxylase Deficiency: A Nationwide Survey in Japan

“…Hyperketonemic hypoglycemia is not only an outcome of adrenal crisis, but also a possible precipitating factor of adrenal crisis during these ages that may be overlooked. Hypoglycemia often occurs with nonspecific symptoms and signs and seems to be more common in children than in adults [14, 15]. Thus, parents of children with 21-OHD should be informed repeatedly that adrenal crisis could occur during infection and may also occur without any overt precipitating factors.…”

Adrenal Crises in Children: Perspectives and Research Directions

“…This may be reflected in unnecessary presentations for medical care or, alternatively, it may result in failure to take appropriate action in situations where oral stress dosing or administration of parenteral glucocorticoid is required [7, 16]. It is also of concern to note that a proportion of all ACs appear not to be preventable [13, 16], evolving so rapidly that stress dosing is not effective [13, 64]. In addition, some ACs have no obvious precipitant [13, 16, 17].…”

Adrenal Crisis: Still a Deadly Event in the 21st Century

“…37 Because gastroenteritis is a frequent precipitant (or presentation) of an adrenal crisis, [15][16][17][18] and an increase in oral glucocorticoids does not always avert an adrenal crisis, 18,38 there should be a low threshold for early parenteral hydrocortisone administration to ensure adequate systemic absorption in patients who cannot tolerate oral medications or fail to respond to stress doses. Physicians should also consider giving additional doses in severe emotional stress (eg, bereavement) if required.…”