From the Guidelines
For a 41-year-old female with Addison's disease weighing 60.3 kg presenting to the ED, I recommend immediate administration of 100 mg hydrocortisone intravenously as a bolus dose, followed by 50-100 mg IV every 6-8 hours for the first 24 hours. This dosing is based on the most recent and highest quality study available, which prioritizes the management of adrenal crisis in patients with Addison's disease 1. The study emphasizes the importance of prompt treatment with stress-dose glucocorticoids to prevent life-threatening complications such as cardiovascular collapse and hypoglycemia.
Key Considerations
- The patient's lack of ability to increase endogenous cortisol production during stress necessitates high initial doses of hydrocortisone
- Adequate fluid resuscitation with normal saline is crucial to correct potential hypovolemia and electrolyte abnormalities
- Close monitoring of vital signs, electrolytes, and glucose levels is essential during treatment
- After clinical improvement, transition to oral hydrocortisone at 20-30 mg daily in divided doses (typically 15-20 mg in the morning and 5-10 mg in the afternoon) is recommended
Additional Recommendations
- Education on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis is vital 1
- A medical alert bracelet or necklace for adrenal insufficiency can help trigger stress dose corticosteroids by emergency medical personnel
- Endocrine consultation should be part of planning before surgery or high-stress treatments, and early consultation is appropriate for patients with Addison's disease 1
From the Research
Hydrocortisone Dosing for Addison's Disease
- The appropriate hydrocortisone dosing for a 41-year-old female patient with Addison's disease is not explicitly stated in the provided studies for a patient of this specific weight and in the Emergency Department (ED) setting.
- However, according to 2, patients presenting with an acute adrenocortical crisis should be treated with 100mg of hydrocortisone and saline intravenously without awaiting laboratory results.
- For maintenance therapy, 3 suggests starting doses of glucocorticoids should be 15 - 20 mg for hydrocortisone, divided into two or three doses, and preferentially weight-adjusted.
- 4 recommends a daily starting dose for hydrocortisone of 20 mg, divided into two or preferably three doses.
- It is essential to note that these recommendations are general and may need to be adjusted based on individual patient needs and responses to treatment, as well as the specific clinical context, such as the Emergency Department setting 2, 3, 4, 5.
- Additionally, 6 highlights the importance of considering the clinical presentation and laboratory results, including cortisol and corticotropin concentrations, in diagnosing and managing primary adrenal insufficiency.
- The use of new treatment modalities, such as modified-released hydrocortisone and continuous subcutaneous hydrocortisone infusion, may offer closer simulation of the physiological serum cortisol rhythm and improved patient outcomes 5.