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Adrenal crisis — MCCQE Part 1 MCQ

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HardWeaknessAdrenal crisisMCCQE Part 1

A 35-year-old man abruptly stopped chronic prednisone used for vasculitis. He now has vomiting, blood pressure 78/46 mm Hg, sodium 126 mmol/L and glucose 3.1 mmol/L. Adrenal crisis from glucocorticoid-induced adrenal insufficiency is suspected. Which immediate treatment is most appropriate?

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Reveal the answer and explanation

Correct answer: D — Give hydrocortisone 100 mg IV now with rapid 0.9% saline, then 200 mg over 24 hours

Option D is correct. Adrenal crisis is a clinical emergency, and treatment must not wait for cortisol testing. The 2024 Endocrine Society joint guideline recommends hydrocortisone 100 mg intravenously or intramuscularly immediately, together with rapid volume resuscitation using 0.9% saline. Confirmed crisis is then treated with hydrocortisone 200 mg over 24 hours, preferably by continuous infusion or alternatively 50 mg every 6 hours, until clinical recovery. Hypoglycaemia also requires prompt dextrose, but dextrose alone does not correct cortisol deficiency or shock. Low-dose oral prednisone is inadequate in a vomiting, haemodynamically unstable patient. Glucocorticoid-induced adrenal insufficiency generally preserves aldosterone, so fludrocortisone alone is neither mechanistically appropriate nor adequate emergency therapy. Blood for cortisol and ACTH can be drawn first only if this causes no treatment delay.

Reference: European Society of Endocrinology and Endocrine Society, 2024 Joint Guideline: https://academic.oup.com/jcem/article/109/7/1657/7667842