Management of Adrenal Emergencies in Educated Patients With Adrenal Insufficiency

A Prospective Study

Stephanie Burger-Stritt; Pavel Kardonski; Alina Pulzer; Gesine Meyer; Marcus Quinkler; Stefanie Hahner


Clin Endocrinol. 2018;89(1):22-29. 

In This Article

Abstract and Introduction


Objective: To evaluate the management of adrenal emergencies (AE) requiring parenteral glucocorticoid (GC) treatment in patients with chronic adrenal insufficiency (AI).

Design: Prospective, multicentre, questionnaire–based study.

Patients and measurements: Participating patients (n = 150) with chronic AI were provided with a questionnaire on the management of emergency situations, which had to be completed and sent back in case of an AE. In addition, patients were contacted by phone on a regular basis.

Results: Fifty–nine AE in 39 patients were documented. The time interval from contact to arrival of a medical professional was 20 minutes (1–240). In total, in 43 AE, patients received parenteral GC by a medical professional. The time interval between showing the emergency card and GC injection by a medical professional was 60 minutes (5–360). A total of 26 patients administered GC by self–injection. The time from the beginning of symptoms to GC injection was significantly shorter in case of self–injection (self–injection vs injection by medical professional; 85 minutes [20–280] vs 232.5 minutes [1–3135]; P < .001). After self–injection, 62% of the patients were treated outpatient, compared to 27% of the patients after exclusive injection by a medical professional (P = .008). To improve the emergency management, most of the patients (84%) indicated a need for an easier way of self–injection.

Conclusion: While management of AE by both patients and medical professionals still shows high variability, patients profit from the option of self–injection. Patient care, including education of patients and health–professionals, as well as the way of GC administration, needs further optimization.


Despite established hormone replacement therapies, the mortality in patients with chronic adrenal insufficiency (AI) is increased compared to the general population.[1–5] The relative risk to die from infectious disease was 6.6–fold increased in a Swedish analysis.[1] It is assumed that adrenal crisis (AC) contributes to the increased mortality in AI patients.[6] The documented incidence of AC varies between 6 and 17 AC/100 patient–years.[7–11] A prospective study revealed a frequency of about 8 AC/100 patient–years and a crisis associated mortality of 0.5 per 100 patient–years for patients with AI.[12] The worsening of the clinical condition frequently occurs rapidly.[7] As an increase in cortisol secretion is an important adaptive mechanism during stress, AC usually occurs in case of a relative cortisol deficit during stressful events (eg, infectious disease).[6,13] A quick and sufficient treatment by parenteral glucocorticoid (GC) administration is essential.[14]

However, parenteral GC administration in case of an emergency is often delayed. A retrospective study comparing reported time intervals with time targets recommended by an European expert panel revealed a delay of GC administration by medical professionals in 46% of cases. Only 54% of the patients received GC parenterally within 30 minutes (with a range of 2–2400 minutes) after presentation of the emergency card to the medical professional. Experts considered 30 minutes as a time limit for "card–injection–time" in case of an AC within the same trial.[15] Further studies indicate an insufficient knowledge of physicians on AI.[16,17] Only 9.6% of the interviewed physicians identified all situations requiring GC adjustment correctly.[16] An inadequate management by medical professionals, leading to an increased risk to die from AC, is assumed. Equipment of patients with an emergency card and set (GC ampoules) and education in dose adaption as well as self–injection of GC[18–20] is recommended by guidelines.[14]

In our recent retrospective analysis of management of AC, patients had been asked about crisis events that were several years ago.[15] It is thus highly likely that patients could not exactly remember the circumstances. To validate and extend the data obtained, we performed a prospective study on emergency management.