A patient on long-term prednisolone presents shocked after gastroenteritis. Manage.

Question

A 48-year-old woman with rheumatoid arthritis on prednisolone 7.5mg daily for 6 years presents with 24 hours of vomiting and diarrhoea. She is drowsy, BP 78/44, HR 132, glucose 3.1, Na 128, K 5.7.

Accepted Answer

This is an adrenal crisis until proven otherwise — long-term steroid use plus shock with hyponatraemia, hyperkalaemia and hypoglycaemia is the classic combination. ABCDE with simultaneous treatment. I would give 100mg IV hydrocortisone immediately without waiting for biochemical confirmation, then 200mg over 24 hours by infusion or 50mg six-hourly. Resuscitate with 1L 0.9% saline over the first hour, repeated as needed; treat hypoglycaemia with 100ml of 20% dextrose IV. If feasible I would send paired cortisol and ACTH before further steroid doses, but not at the cost of delaying treatment. Identify and treat the precipitant — here gastroenteritis — with fluids, antiemetics and investigation for infection. Monitor in HDU. Before discharge I would ensure she has a steroid emergency card, an IM hydrocortisone emergency kit with training (her and a family member), written sick-day rules (double oral dose for moderate illness, IM hydrocortisone if vomiting), and endocrinology follow-up. I would also flag her on the GP record and the trust electronic system. The aim is that the next time this happens, she or her family act before she becomes critically unwell.

Adrenal crisis in a steroid-dependent patient

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