Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- sudden cessation or rapid tapering of glucocorticoids
- acute circulatory collapse with hypotension and tachycardia
Other diagnostic factors
- lassitude and generalized constitutional symptoms
- history of weight gain and increased appetite
- history of depression, agitation, or sleep disorders
- cushingoid exam features
- history of difficult-to-control diabetes or hypertension
- absence of hyperpigmentation or autoimmune stigmata
- medroxyprogesterone use
- history of treatment for endogenous Cushing syndrome
Risk factors
- systemic glucocorticoid administration
- high potency or dose of exogenous glucocorticoids
- prolonged glucocorticoid treatment (e.g., >3 weeks)
- local glucocorticoid administration
- megestrol use
- nonphysiologic scheduling of glucocorticoid dose
- medroxyprogesterone use
Diagnostic investigations
1st investigations to order
- serum comprehensive chemistry panel
- serum a.m. cortisol
- salivary a.m. cortisol
- adrenocorticotropic hormone (ACTH) stimulation test
- CBC
- thyroid function tests
Investigations to consider
- insulin tolerance test (ITT)
- overnight metyrapone test
- urine synthetic glucocorticoids
Treatment algorithm
features of adrenal crisis
minor intercurrent stress
severe intercurrent stress
stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
Contributors
Authors
Suzanne L. Quinn Martinez, MD
Staff Endocrinologist
Orlando Veterans Administration Hospital
Associate Professor Internal Medicine
University of Central Florida
Orlando
FL
Disclosures
SLQM declares that she has no competing interests.
Acknowledgements
Dr Suzanne L. Quinn Martinez would like to gratefully acknowledge Dr M. Cecilia Lansang, a previous contributor to this topic.
Disclosures
MCL is a consultant for the Sanofi group of companies and is an author of several references cited in this topic.
Peer reviewers
Diane Mary Donegan, MB BCh BAO, MRCPI, Ms
Assistant Professor of Medicine
Indiana University
Indianapolis
MI
Disclosures
DMD is a member of a paid advisory board for Recordati and Corcept. DMD is also a site investigator for Corcept and Chiasma.
Antoine Tabarin, MD
Head
Department of Endocrinology
University Hospital of Bordeaux
Pessac
France
Disclosures
AT declares that he has no competing interests.
Maralyn Druce, MA, MBBS, MRCP, PhD
Clinical Lecturer
Honorary Consultant
Department of Endocrinology
Barts and The London School of Medicine and Dentistry
St Bartholomew's Hospital
London
UK
Disclosures
MD declares that she has no competing interests.
Differentials
- Primary adrenal insufficiency
- Pituitary compression, tumor, head trauma, and surgery (non-Cushing)
- Corticosteroid withdrawal syndrome
More DifferentialsGuidelines
- Adrenal suppression from exogenous glucocorticoids: recognizing risk factors and preventing morbidity
- Emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients
More Guidelines
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