VIENNA — Adrenal crisis is uncommon but potentially fatal, and many cases could be prevented through better education of patients, families, and clinicians, according to a presentation here at the European Congress of Internal Medicine 2026.

In an overview of adrenal insufficiency and adrenal crisis, Peter Wolf, MD, PhD, Medical University of Vienna, Austria, emphasized that prevention is the central message because even though treatment is straightforward, delayed recognition can be dangerous.

“Adrenal crisis is rare but potentially life-threatening and preventable,” said Wolf. “It is one of the few endocrine emergencies in which prompt recognition and simple action can save lives. The most important thing is to educate patients, their families, and healthcare professionals.”

The talk focused on the causes of adrenal insufficiency, the warning signs of adrenal crisis, and the practical steps needed to manage and prevent it. Wolf explained that cortisol is the body’s main hormone, meaning patients with adrenal insufficiency may be unable to mount an adequate response to infection, fever, pain, gastrointestinal illness, or other acute stressors.

“That is what makes adrenal crisis so dangerous,” he said. “In patients with adrenal insufficiency, especially primary adrenal insufficiency, illness or other stress can trigger rapid clinical deterioration, including hypotension, hemodynamic instability, hypoglycemia, and impaired mental status.”

Educate Patients and Clinicians

The annual incidence of adrenal crisis in patients with adrenal insufficiency is around 6%-8%, Wolf noted, and mortality remains concerning at about 1%. Given that risk, the most important intervention is prevention.

“Patients need to increase glucocorticoid doses during illness or stress, typically by doubling or tripling their usual hydrocortisone dose, depending on severity. They also need to recognize when oral medication is no longer sufficient and when urgent hospital care is required.”

Because gastrointestinal infections are a major trigger, patients should also be taught alternative routes of administration, including emergency self-injection when oral medication cannot be retained. “Education of patients, families, and clinicians is essential,” said Wolf.

Causes and Clinical Clues

Wolf reviewed the major forms of adrenal insufficiency. 

Primary adrenal insufficiency results from destruction of the adrenal gland, most commonly due to autoimmune disease. In these patients, cortisol and aldosterone production fall, while adrenocorticotropic hormone (ACTH) levels rise because of loss of negative feedback.

Secondary adrenal insufficiency occurs when the pituitary fails to produce enough ACTH. 

Tertiary adrenal insufficiency usually reflects hypothalamic suppression, most often after long-term use of exogenous glucocorticoids.

Wolf noted that in current clinical practice, immune checkpoint inhibitor therapy is becoming an increasingly important cause of secondary adrenal insufficiency in oncology patients. Exogenous glucocorticoid use remains a very common cause overall and may be overlooked when exposure comes from topical or other nonoral preparations.

Clinical signs are often nonspecific and may include progressive fatigue, weight loss, abdominal pain, hyponatremia, and hypoglycemia. In primary adrenal insufficiency, hyperpigmentation may occur because elevated ACTH stimulates melanocytes. Aldosterone deficiency may contribute to low blood pressure, volume depletion, hyponatremia, and hyperkalemia.

“Morning cortisol testing can help guide diagnosis, although borderline cases may still require further workup,” Wolf said.

Treat First, Confirm Later

Routine treatment of adrenal insufficiency consists of hormone replacement therapy, usually with hydrocortisone at higher doses in the morning and lower doses in the early afternoon, to mimic the body’s normal circadian rhythm, Wolf explained.

But the emergency setting is different, he noted. “In adrenal crisis, the immediate priority is glucocorticoid treatment, fluid replacement, and correction of hypoglycemia if present.”

The recommended treatment is 100-mg intravenous hydrocortisone as an immediate bolus, followed by 200 mg over the next 24 hours, either as a continuous infusion or in divided doses. Volume replacement with isotonic saline is also essential. Intravenous glucose should be provided if hypoglycemia is present, and the patient may be switched to oral hydrocortisone after clinical improvement.

Wolf stressed that treatment should not be delayed while waiting for confirmation. “In any unstable patient in whom adrenal insufficiency is suspected, clinicians should treat first and investigate later, because the risk of missing a life-threatening crisis outweighs the downside of giving empiric steroids.”

He also highlighted a practical point for emergency and acute care clinicians: It is not necessary to wait for hydrocortisone specifically if it is not immediately available.

Hospitals sometimes call endocrine teams to ask whether patients should be transferred because hydrocortisone is not on hand, he said. But in the emergency setting, it is more important to give any available glucocorticoid than to delay treatment.

Simple Treatment, Difficult Prevention

Although adrenal crisis is medically straightforward to treat, preventing it is difficult in practice, Wolf said. “Even when patients receive education, they may not carry emergency cards, may not remember sick day rules, or may delay using self-injection kits,” he said, adding that “clinicians, too, may fail to consider adrenal crisis because the condition is relatively rare and early features are nonspecific.”

During the discussion, internist Professor Dagmar Führer-Sakel, MD, PhD, University Hospital Essen, University of Duisburg-Essen, Germany, remarked, “Many patients do not have their emergency medication with them, raising the possibility that reminders or digital tools may help reinforce prevention messages.”

Wolf acknowledged that this remains a challenge. Standardized patient education has not always translated into marked reductions in adrenal crisis rates, suggesting that more work is needed to support patients in real-world settings.

Also commenting, co-moderator Miryam Oberle, MD, a general practitioner from Graubünden, Switzerland, said, “I think it’s important because it is rare, but at the same time it’s something we can prevent if we know what to do.”

“We also have to recognize how dangerous it is. It’s not the first thing you think of, but you need to keep it in the back of your mind; to ask, could this be it? Because if it is, you must not miss it.”

Wolf, Führer-Sakel, and Oberle reported no relevant financial relationships.