100 mg intravenous bolus stat followed by 50–100 mg intravenous or intramuscular four times a day continued for 24–48 hours until the patient can take oral medication (alternative 200 mg/24 hours by continuous intravenous infusion).

Fludrocortisone should be restarted when the hydrocortisone dose falls to <50 mg/day.

Dehydroepiandrosterone replacement is not required.

Monitor renal profile at least every 12 hours and continue regular monitoring until electrolyte imbalance and acute kidney injury are corrected.

1 L normal saline intravenous infusion over an hour followed by repeated infusion at a slower rate (usually 4–6 L in 24 hours).

Frequent haemodynamic monitoring and measurement of serum electrolytes to avoid fluid overload.

Admission to the high-dependency unit.

Prophylaxis of gastric stress ulcer and low-dose heparin.

Antibiotic treatment.

Explore the medical and behavioural causes precipitating adrenal crisis, (eg, compliance issues).

Patient education.

Annual influenza immunisation (and pneumococcal vaccination when older than 60 years).

Emergency hydrocortisone injection (every patient should be issued with an emergency injection kit and advised of training for patients and carers/families on their use).

Sick day rules guidance.

Advise to register with local ambulance service as ‘steroid dependent’.

Steroid card/medic bracelet.