What is the treatment for adrenal crisis (Addisonian crisis)?

From the Guidelines

Immediate treatment of an Addisonian crisis requires prompt administration of hydrocortisone 100mg intravenously as a bolus, followed by continuous infusion of 200-300mg over 24 hours or 50-100mg every 6-8 hours, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment approach for Addisonian crisis involves several key components:

• Hydrocortisone administration: 100mg intravenous bolus, followed by continuous infusion of 200-300mg over 24 hours or 50-100mg every 6-8 hours 1
• Fluid resuscitation: rapid administration of 1-2 liters of normal saline within the first hour to correct hypotension and hypovolemia, followed by continued fluid replacement as needed 1
• Blood glucose monitoring: close monitoring of blood glucose levels, with dextrose administration if hypoglycemia is present 1
• Transition to oral hydrocortisone: once the patient is stabilized, typically within 24-48 hours, transition to oral hydrocortisone at 15-20mg in the morning and 5-10mg in the afternoon can begin 1
• Fludrocortisone addition: fludrocortisone (0.05-0.2mg daily) should be added once IV hydrocortisone is discontinued to provide mineralocorticoid replacement 1

Key Considerations

• The underlying trigger for the crisis should be identified and treated 1
• Hydrocortisone is essential in this emergency because it replaces the cortisol that the adrenal glands cannot produce, which is critical for maintaining blood pressure, glucose levels, and the body's stress response 1
• Fluid replacement addresses the dehydration and hypotension that result from mineralocorticoid deficiency, which causes sodium loss and potassium retention 1

Patient Management

• Patients with a long-standing diagnosis of adrenal insufficiency are often well informed about their disease, and anaesthetists should enquire closely about the patient’s history of glucocorticoid self-management, any previous episodes of adrenal crisis, and how practised they are at medication adjustments for illness, injury, or postoperative recovery 1
• Best practice is to collaborate as far as possible with the patient’s endocrinologist when planning scheduled surgery, and when caring for postoperative patients 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. In Addison's disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects.

The treatment for Addison crisis is not directly addressed in the provided drug labels.

• The labels discuss the treatment of Addison's disease with fludrocortisone acetate tablets in combination with a glucocorticoid such as hydrocortisone or cortisone.
• However, the labels do not provide specific guidance on treating an Addison crisis, which is a life-threatening complication of Addison's disease. 2

From the Research

Treatment of Addisonian Crisis

The treatment of Addisonian crisis involves immediate parenteral hydrocortisone administration, as stated in the study 3. The recommended dose is a 100 mg bolus, followed by a continuous infusion until the underlying cause is resolved and regular supplementation can be continued.

Key Components of Treatment

• Immediate administration of parenteral hydrocortisone (100 mg bolus) 3
• Continuous infusion of hydrocortisone until the underlying cause is resolved 3
• Regular supplementation can be continued once the patient is stable 3

Importance of Early Recognition and Treatment

Early recognition and treatment of Addisonian crisis are crucial to prevent mortality, as highlighted in the study 3. Patients, relatives, and spouses should be educated on prevention and early recognition of the condition through educational programs and emergency cards.

Additional Considerations

• Patients with Addison's disease may be undertreated with fludrocortisone, as suggested in the study 4
• The dose of fludrocortisone should be adjusted according to plasma-renin activity and 24 h urinary sodium excretion 4
• Recent research focuses on the development of pharmacokinetically optimized glucocorticoid preparations and regenerative therapies 5