The new england journal of medicine n engl j med 381;9 nejm.org August 29, 2019 852 Review Article G lucocorticoid replacement therapy, available since the 1950s, has prolonged the survival of patients with adrenal insufficiency. 1 How- ever, adrenal crises, which are life-threatening medical emergencies, still develop in many affected patients. Adrenal crisis appears to be increasing in fre- quency, despite the availability of effective preventive strategies. 2-4 This review exam- ines the definitions, pathophysiology, epidemiology, and treatment of adrenal crises. Definitions of Adrenal Crisis There is no universally accepted definition of an adrenal crisis, also called acute adrenal insufficiency or addisonian crisis. 5 Generally, acute physiological distur- bances in patients with known hypoadrenalism are labeled as adrenal crises on the basis of clinical assessment. 2,5,6 Diagnostic misclassification may not alter im- mediate management but, at the epidemiologic level, can impede an understand- ing of the nature of adrenal crises. Given the lack of a research-based classification and in recognition of the physiological changes that distinguish an adrenal crisis from a milder episode of hypoadrenalism, 5-11 pragmatic definitions of adrenal crisis have generally been adopted. 2,5,8,9 An adrenal crisis in an adult is defined as an acute deteriora- tion in health status associated with absolute hypotension (systolic blood pressure <100 mm Hg) or relative hypotension (systolic blood pressure ≥20 mm Hg lower than usual), with features that resolve within 1 to 2 hours after parenteral gluco- corticoid administration (i.e., a marked resolution of hypotension within 1 hour and improvement in clinical symptoms over a period of 2 hours). Since identification of hypotension in infants and young children during an emergency may be difficult, an adrenal crisis in this age group is defined as an acute deterioration in health status associated with an acute hemodynamic distur- bance (hypotension or sinus tachycardia relative to age-related normative data) or a marked electrolyte abnormality (e.g., hyponatremia, hyperkalemia, or hypoglyce- mia not attributable to another illness). After parenteral glucocorticoid adminis- tration, the features ascribed to adrenal crisis resolve substantially. 12-16 Concomitant features in patients of all ages include acute abdominal symp- toms; delirium, obtundation, or both; and hyponatremia, hyperkalemia, hypo- glycemia, and pyrexia. 5-11 When hypotension ascribed to an adrenal crisis does not respond or responds poorly to glucocorticoid administration, the coexistence of other illnesses associated with hypotension, such as sepsis, should be considered. Adrenal crises are the most severe manifestation of adrenal insufficiency, but they share symptoms with milder hypoadrenal states. These symptoms include anorexia, nausea, vomiting, fatigue, postural dizziness, abdominal pain, limb and back pain, and impaired consciousness. Shared biochemical perturbations include From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Ade- laide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) — all in Australia; and the Department of Endocrinology, Metabolism and Diabe- tes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stock- holm (H.F.). Address reprint requests to Dr. Falhammar at the Department of Mo- lecular Medicine and Surgery, D2:04, Karo- linska Institutet, SE-171 76 Stockholm, Sweden, or at [email protected]. N Engl J Med 2019;381:852-61. DOI: 10.1056/NEJMra1807486 Copyright © 2019 Massachusetts Medical Society. Julie R. Ingelfinger, M.D., Editor Adrenal Crisis R. Louise Rushworth, M.B., B.S., Ph.D., David J. Torpy, M.B., B.S., Ph.D., and Henrik Falhammar, M.D., Ph.D. The New England Journal of Medicine Downloaded from nejm.org at MACQUARIE UNIVERSITY on August 28, 2019. For personal use only. No other uses without permission. Copyright © 2019 Massachusetts Medical Society. All rights reserved.
Adrenal Crisis
Apr 28, 2023
There is no universally accepted definition of an adrenal crisis, also called acute
adrenal insufficiency or addisonian crisis.5
Generally, acute physiological disturbances in patients with known hypoadrenalism are labeled as adrenal crises on
the basis of clinical assessment.2,5,6 Diagnostic misclassification may not alter immediate management but, at the epidemiologic level, can impede an understanding of the nature of adrenal crises.
Welcome message from author
Glucocorticoid replacement therapy, available since the 1950s, has prolonged the survival of patients with adrenal insufficiency.1
However, adrenal crises, which are life-threatening medical emergencies, still develop in many affected patients. Adrenal crisis appears to be increasing in frequency, despite the availability of effective preventive strategies
Related Documents
![Understanding adrenal crisis - Home - Springer · PDF fileUnderstanding adrenal crisis ... sollevelmeasurementmaynotbereliable[13]inacon-textofalteredcorticosteroidbindingproteinreleaseand](https://static.cupdf.com/doc/110x72/5ab7c97e7f8b9ac10d8c2959/understanding-adrenal-crisis-home-springer-adrenal-crisis-sollevelmeasurementmaynotbereliable13inacon-textofalteredcorticosteroidbindingproteinreleaseand.jpg)
