A patient with primary adrenal insufficiency has been stable on hydrocortisone 20 mg/10 mg and fludrocortisone 0.1 mg daily. She develops vomiting, fever 38.8°C, and BP 80/50 mmHg. Which is the most appropriate immediate management?

• A Double oral hydrocortisone dose and increase fludrocortisone
• B IV dexamethasone 4 mg to avoid interfering with cortisol assay
• C IV methylprednisolone 125 mg and hold fludrocortisone
• D IV hydrocortisone 100 mg bolus followed by 200 mg over 24 hours plus IV saline ✓

Explanation

Adrenal crisis requires immediate IV hydrocortisone 100 mg bolus followed by 200 mg/24 h (continuous or 6-hourly 50 mg dosing) combined with aggressive IV 0.9% saline for volume resuscitation. Oral therapy is inappropriate when vomiting is present. Dexamethasone can be used pre-diagnosis to avoid interfering with the SST, but in a known adrenal insufficiency patient with crisis, hydrocortisone is preferred as it also has mineralocorticoid activity at high doses, making separate fludrocortisone unnecessary during crisis. This follows current Endocrine Society emergency guidelines.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.