Adrenal crisis: a case-based approach

The presentation

Imagine an adult who takes daily steroid tablets for Addison's disease. They have had a vomiting bug for a day, could not keep tablets down, and are now weak, dizzy, drowsy and being sick again. Their blood pressure is low, they look pale and clammy, and they complain of tummy and back pain. This picture — someone dependent on steroids who becomes acutely unwell, especially with vomiting, diarrhoea, infection or injury — is the classic setting for adrenal crisis. The body cannot make its own extra cortisol to cope with the stress of illness, and without it, blood pressure and blood sugar fall dangerously. Recognising that a steroid-dependent person who is collapsing needs emergency steroid, not just rest, is the key insight.

Why it happens

Cortisol is a hormone that helps the body handle stress, keep blood pressure up and steady blood sugar. Normally the adrenal glands pour out extra cortisol during illness, injury or surgery. In people with Addison's disease the glands cannot do this, and in people on long-term steroid medicines the body's own supply is switched off, so they too rely entirely on their tablets. When such a person becomes ill and cannot absorb or take enough steroid — for example through vomiting — cortisol runs short just when the body needs it most. Blood pressure drops, salts become unbalanced, blood sugar can fall, and the person spirals towards collapse. This is why sick-day rules and an emergency steroid injection matter so much: they replace the cortisol the body cannot supply.

The warning signs

Adrenal crisis can come on over hours. Watch for severe weakness and exhaustion, dizziness or fainting from low blood pressure, and nausea, vomiting or diarrhoea that stops steroid being absorbed. There may be tummy, back or leg pain, confusion or drowsiness, and cold clammy skin. Some people describe a deep sense of feeling dreadfully unwell. It is often triggered by an infection, a stomach bug, a missed steroid dose, surgery, injury or intense stress. In known Addison's disease, the skin may look tanned or darker. Anyone who takes long-term steroids or has adrenal problems and becomes suddenly and severely unwell — particularly if they are vomiting and cannot keep tablets down — should be treated as a possible adrenal crisis and given emergency help without delay.

Sick-day rules and emergency steroid

People who depend on steroids are usually taught sick-day rules: when unwell with fever or infection, they temporarily increase their steroid dose as their team advises, and they never stop steroids suddenly. If they cannot keep tablets down because of vomiting or diarrhoea, tablets alone will not work and an emergency hydrocortisone injection is needed, followed by urgent medical help. Many carry a steroid emergency card and an injection kit, and family members can be shown how to give it. Wearing a medical alert bracelet helps ambulance crews act fast. The safest habit is to treat early rather than wait: giving the emergency injection and calling for help when in doubt is far safer than delaying and risking collapse. This guide does not cover doses — those come from the person's own team.

The safe pathway

The practical rule is simple. Someone on steroids with a mild illness who is alert, keeping fluids and tablets down and following their sick-day rules can often be managed at home with closer monitoring and advice from their team or NHS 111. But if they become very weak, dizzy or faint, are vomiting and cannot keep steroid down, become drowsy or confused, or collapse, this is a life-threatening emergency. Call 999 immediately, say clearly that the person is steroid-dependent and may be having an adrenal crisis, and give their emergency hydrocortisone injection if trained and it is available. Adrenal crisis is treated in hospital with steroid and fluids into a vein, and people recover well when treated quickly — so never wait to see if things settle.