Our bodies have a remarkable, built-in system for managing stress. Whether facing an illness, an injury or immense emotional pressure, a pair of tiny glands releases a powerful hormone that helps our body cope. But what happens when this system fails? For individuals with a condition called adrenal insufficiency, the body cannot produce enough of this vital hormone, cortisol. This deficiency can suddenly escalate into an acute adrenal crisis, a life-threatening medical emergency where the body effectively goes into shock. Understanding what an adrenal crisis is, what triggers it and the critical importance of immediate intervention is essential knowledge for patients, families and caregivers, as swift action is the key to preventing a tragic outcome.

Acute adrenal crisis, also known as adrenal insufficiency crisis or Addisonian crisis, is the most severe and dangerous manifestation of adrenal insufficiency. It is a state of physiological collapse that occurs when the body’s levels of cortisol are critically low and cannot meet the body’s needs during a period of physical stress.

To understand this crisis, we must first appreciate the role of the adrenal glands and the hormone cortisol. Situated on top of each kidney, the two adrenal glands are responsible for producing several essential hormones. The most critical of these for managing stress is cortisol. Often called the “stress hormone,” cortisol plays a fundamental role in nearly every part of the body. It helps to:

• Maintain blood pressure and cardiovascular function.
• Regulate the immune system’s inflammatory response.
• Balance the effects of insulin to keep blood sugar levels stable.
• Regulate metabolism of proteins, carbohydrates, and fats.

In a healthy person, the body dramatically increases its cortisol production in response to stress, such as an infection or injury. This “stress dose” of cortisol is vital for survival. An acute adrenal crisis occurs in someone whose adrenal glands cannot produce this necessary surge. Without adequate cortisol, blood pressure plummets, blood sugar drops dangerously, and the body descends into a state of shock, which can quickly lead to coma and death if not treated immediately.

Adrenal crisis is an emergency that can escalate rapidly. A patient may seem mildly ill at first, but within hours, they’re hypotensive, confused and at risk of organ failure.

Analogy: Think of cortisol like your body’s shock absorber during stress. Without it, every stressor, an infection, injury, or even fasting, hits the body hard, like a car without brakes hitting a pothole. That’s what happens during adrenal crisis.

The root cause of an acute adrenal crisis is always an underlying condition called adrenal insufficiency, which means the body is incapable of making enough cortisol. An adrenal crisis is the acute decompensation of this chronic condition. There are two main types of adrenal insufficiency.

1. Primary Adrenal Insufficiency (Addison’s Disease): In this form, the problem lies directly with the adrenal glands themselves. They have been damaged and have lost their ability to produce cortisol (and often another hormone called aldosterone). The most common cause of Addison’s disease in developed countries is an autoimmune disorder, where the body’s own immune system mistakenly attacks and destroys the adrenal cortex. Other causes include:

• Infections, such as tuberculosis (a significant cause in many parts of the world), fungal infections, or HIV-related infections.
• Bleeding into the adrenal glands (adrenal hemorrhage).
• Cancer that has spread (metastasized) to the adrenal glands.

2. Secondary Adrenal Insufficiency: In this form, the adrenal glands are healthy, but they don’t receive the proper signal from the brain to do their job. The pituitary gland, a small gland at the base of the brain, is responsible for producing Adrenocorticotropic Hormone (ACTH). ACTH is the messenger hormone that travels to the adrenal glands and tells them to release cortisol. If the pituitary gland is damaged and fails to produce enough ACTH, the adrenal glands will not produce cortisol.

The most common cause of secondary adrenal insufficiency is the long-term use of high-dose glucocorticoid (steroid) medications, such as prednisone. These medications are used to treat a wide range of inflammatory conditions, like asthma, rheumatoid arthritis, or lupus. When a person takes external steroids for a long time, their pituitary gland stops sending the ACTH signal, and their own adrenal glands can become dormant. Other causes include pituitary tumors, surgery, or radiation therapy to the brain.

Often, the most dangerous cause is sudden stopping of steroid medications, often when patients discontinue them without tapering, not realizing their body has become dependent.

You can develop an adrenal crisis if your body is already deficient in cortisol and then faces a stressful event that increases demand. For these individuals, their daily steroid replacement medication is enough for normal life, but it is not enough to handle a major physical stressor.

The most common triggers that can push a person with adrenal insufficiency into a life-threatening crisis include:

• Illness or Infection: This is the most frequent trigger. Even a common illness like the flu, a stomach bug (gastroenteritis) with vomiting and diarrhea, or a more serious infection like pneumonia can demand a cortisol surge that the body cannot provide.
• Physical Trauma: A significant injury such as a car accident, a broken bone, or a major burn places immense stress on the body.
• Surgery: The physical stress of a surgical procedure and anesthesia requires a significant cortisol response. Patients with known adrenal insufficiency require extra steroid coverage before, during, and after surgery.
• Sudden Withdrawal of Steroid Medication: This is a critical point for anyone on long-term steroid therapy. If these medications are stopped abruptly rather than being tapered down slowly under a doctor’s supervision, the dormant adrenal glands cannot “wake up” fast enough to produce cortisol, leading to secondary adrenal insufficiency and a potential crisis.
• Dehydration: Severe dehydration from any cause, but especially from vomiting or diarrhea, can precipitate a crisis.
• Intense Emotional or Psychological Stress: While less common as a sole trigger, severe emotional trauma can contribute to the body’s overall stress load.

Adrenal crisis symptoms can appear suddenly and worsen quickly. The classic triad includes hypotension (low blood pressure), dehydration, and shock. It is imperative for patients and their families to recognize this dangerous constellation of symptoms.

The key signs and symptoms include the following:

• Severe Gastrointestinal Symptoms:
  • Sudden, intense pain in the lower abdomen, back, or legs
  • Severe, uncontrollable vomiting and diarrhea
• Symptoms of Shock (from very low blood pressure):
  • Extreme lightheadedness or dizziness upon standing
  • A rapid, weak pulse
  • Cold, clammy skin
• Neurological Symptoms:
  • Profound weakness and fatigue
  • Confusion, disorientation, or slurred speech
  • In severe cases, loss of consciousness or coma
• Other Signs:
  • High fever
  • Low blood sugar (hypoglycemia)
  • Laboratory tests will often show low sodium and high potassium levels in the blood

An acute adrenal crisis is a medical emergency that requires immediate and aggressive treatment to prevent death. Management principles are simple: give steroids immediately and correct the dehydration and low blood pressure.

What To Do in an Emergency

For individuals with a known diagnosis of adrenal insufficiency, education is the key to survival.

1. Administer Emergency Hydrocortisone: Patients should be prescribed an emergency injection kit containing a vial of hydrocortisone and a syringe. The patient and their family members must be trained on how to give this injection into the thigh muscle at the first sign of a developing crisis. This injection can be lifesaving and should be given without hesitation.
2. Call for Emergency Medical Services: Immediately after giving the injection, call an ambulance or go to the nearest emergency department. Inform the dispatcher and paramedics that you have adrenal insufficiency and are experiencing an adrenal crisis.
3. Medical Alert Identification: All individuals with adrenal insufficiency should wear a medical alert bracelet or necklace at all times. This speaks for you when you cannot, informing medical personnel of your condition and the need for immediate steroids.

Hospital Treatment

In the hospital, treatment will be swift and will not wait for laboratory confirmation.

• Intravenous (IV) Steroids: High-dose hydrocortisone will be given directly into a vein.
• IV Fluids: Large volumes of intravenous saline with dextrose (sugar) will be given to rapidly raise blood pressure, correct dehydration, and treat low blood sugar.
• Supportive Care: The patient will be closely monitored in the hospital. Doctors will also work to identify and treat the underlying trigger of the crisis, for example, by giving antibiotics for a presumed infection.

Patients often feel dramatically better within hours of starting hydrocortisone; it’s a treatment where the effect is visible and rapid.

Preventing an Adrenal Crisis: The “Sick Day Rules”

For a person living with adrenal insufficiency, prevention is the most important part of management. This revolves around understanding and implementing the “sick day rules” or stress dosing.

• Have a Plan: Every person with adrenal insufficiency should have a clear, written plan from their endocrinologist that outlines exactly how to adjust their medication during different levels of illness or before medical/dental procedures.
• Never Miss a Dose: Take your daily oral steroid medication (like hydrocortisone or prednisone) consistently.
• Double or Triple the Dose: During times of moderate illness (like a cold or a fever), the standard rule is to double or triple your usual daily dose of oral steroids until you are well.
• Seek Medical Advice for Vomiting: If you are vomiting and cannot keep your oral medication down, this is an emergency. You will need a hydrocortisone injection and may need to go to the hospital for IV fluids.

Acute adrenal crisis is a frightening and life-threatening condition, but for those with a known diagnosis of adrenal insufficiency, it is largely preventable. The pillars of safe living with this condition are education, preparation, and empowerment. By consistently wearing a medical alert ID, always carrying a life-saving emergency hydrocortisone injection, and diligently following the “sick day rules” for stress dosing, individuals can protect themselves from a crisis. Recognizing the early warning signs and knowing when to seek immediate medical help is paramount. Understanding adrenal insufficiency and managing it well allows people to live full and independent lives while keeping risks low.

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2018). Adrenal Insufficiency & Addison’s Disease. Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease
• National Organization for Rare Disorders (NORD). (2021). Addison’s Disease. Retrieved from https://rarediseases.org/rare-diseases/addisons-disease/
• National Institutes of Health (NIH). (2023). Adrenal Crisis. MedlinePlus. https://medlineplus.gov
• Cleveland Clinic. (n.d.). Adrenal Crisis. Retrieved June 14, 2025, from https://my.clevelandclinic.org