Adrenal Crisis — Recognising It and What to Do Immediately

An adrenal crisis usually builds on vague symptoms present for days or weeks — tiredness, nausea, loss of appetite, and dizziness on standing. The crisis itself arrives suddenly: severe vomiting, sharp abdominal or back pain, extreme weakness, confusion, and a rapid drop in blood pressure that can lead to collapse.

Because the lead-up is so easy to dismiss as "just tiredness" from treatment, a spouse or caretaker is often the first to notice the sudden change — confusion, an inability to stand, or looking far more unwell than usual. Any of these signs is a reason to act immediately, not to wait and watch.

Call emergency services or get the patient to the nearest emergency room immediately — do not wait to see if symptoms pass, and do not attempt to manage a suspected adrenal crisis at home. Every hour of delay increases risk, so acting fast matters more than anything else you can do.

• Call an ambulance or drive straight to the nearest emergency room — do not wait for a scheduled appointment or a callback.
• Bring the steroid emergency card, medical alert bracelet, or a list of current medicines if you have one — hand it to the first staff member you meet.
• Call the CION helpline on the way so the treating oncology team is alerted, but never let that call delay leaving for the hospital.
• Do not give any home remedy, over-the-counter medicine, or "wait and see" treatment — an adrenal crisis needs hospital-level care, not home management.

Tell the emergency team immediately that the patient is on, or has recently received, cancer immunotherapy and may have immune-related adrenal insufficiency — this single sentence changes how quickly they act. Emergency steroid treatment is often started before test results confirm the diagnosis, because delay is the real danger here.

• "They are on cancer immunotherapy and may have immune-related adrenal insufficiency" — say this in the first minute, before anything else.
• Show the steroid emergency card if one has been issued — it is written specifically to tell emergency staff what to do without waiting.
• Give the name and contact details of the treating oncology team so the emergency department can coordinate directly with them.
• Mention any other immune-related reactions the patient has had during immunotherapy — these can be relevant to how the crisis is treated.

Coordination between the emergency team and the oncology team is standard practice for this kind of reaction — you do not need to manage that coordination yourself, only make sure both sides have the information above as early as possible.

Checkpoint immunotherapy can cause the immune system to attack the pituitary or adrenal glands, reducing the hormones that manage blood pressure, blood sugar, and the body's response to physical stress such as infection or injury. When these hormone levels fall too low — often triggered by an illness or a missed dose of prescribed replacement medicine — the body cannot cope with the added stress, and a crisis results.

This is a recognised, guideline-documented immune-related side effect, though it is far less common than milder endocrine reactions such as thyroid changes. NCCN and ASCO both classify it as a high-priority emergency precisely because it can be prevented from becoming life-threatening when recognised and acted on early — which is the entire purpose of this page.

Once emergency treatment has stabilised the crisis, care moves into a structured follow-up pathway involving both the emergency team and your oncology-endocrine team — not a return straight home.

1. 1

   Emergency stabilisation

   The emergency team treats the crisis directly, usually with IV fluids and emergency steroid treatment, without waiting for every test result to come back.

2. 2

   Hormone testing

   Once stabilised, blood tests check how well the pituitary and adrenal glands are working, to confirm the cause and guide next steps.

3. 3

   Oncology-endocrine coordination

   Your oncology team and an endocrinologist review the results together, since the crisis is linked to the immunotherapy you are receiving.

4. 4

   Decision on hormone replacement

   If ongoing hormone replacement is needed, your endocrinologist prescribes and explains it — this is never a decision made or adjusted by the family.

5. 5

   Tumour board decision on immunotherapy

   Your tumour board decides whether, and when, immunotherapy can safely continue, based on how the crisis was managed and how you've recovered.

A steroid emergency card is a small card, usually issued by your endocrinologist or oncology team, stating that the patient depends on prescribed hormone replacement and needs urgent steroid treatment if they become seriously unwell — before test results are even available.

• Who issues it — your endocrinology or oncology team, once hormone replacement has been started or an immune-related adrenal reaction has been confirmed.
• What it tells responders — that emergency steroid treatment should not wait for blood tests to confirm the diagnosis, because delay is the real danger.
• Where to keep it — in a wallet, attached to a phone case, or as a medical alert bracelet or its digital equivalent, wherever it will be found fastest in an emergency.
• Who else should know — at least one family member or caretaker should know exactly where it is kept, not just the patient.

If your loved one has had an immune-related adrenal reaction or has started hormone replacement after immunotherapy and does not yet have one of these cards, ask the treating oncology or endocrine team for one at the next visit.

These companion pages go deeper into specific parts of the same hormone and endocrine irAE pathway — worth bookmarking alongside this one.

• Persistent Tiredness on Immunotherapy: Check Your Hormones — why ongoing fatigue is often the earliest, easiest-to-miss warning sign discussed on this page.
• Will I Need Hormone Tablets for Life After Immunotherapy? — more detail on how the clinician-directed replacement decision described above is actually made.
• Overactive Then Underactive Thyroid: Why It Happens in That Order — a related, more common endocrine reaction worth knowing about too.
• Immunotherapy at CION Cancer Clinics — how we monitor and support patients through immune-related side effects, from the first infusion onward.

Immune Reactions Are Manageable When Caught Early

Patients and families who recognise symptoms early are supported by the same multidisciplinary team throughout treatment.