What is the treatment for an Addisonian crisis?

Treatment of Addisonian Crisis

Immediate treatment of an Addisonian crisis requires 100 mg hydrocortisone IV immediately, followed by continued IV hydrocortisone administration every 6 hours until the patient stabilizes. 1, 2

Initial Emergency Management

1. Immediate interventions:

   • Administer 100 mg hydrocortisone IV bolus immediately without waiting for confirmatory testing 1, 3
   • Begin aggressive fluid resuscitation with isotonic saline to correct hypotension and hypovolemia 1
   • Monitor vital signs, especially blood pressure and heart rate 1
   • Check serum electrolytes (particularly sodium and potassium) and glucose levels 1, 3

2. Continued treatment:

   • Continue hydrocortisone 100 mg IV every 6 hours until the patient stabilizes 2, 1
   • Alternatively, provide 200-300 mg/day as continuous infusion 1
   • Correct hypoglycemia with glucose administration if present 4
   • Address electrolyte abnormalities, particularly hyponatremia 4

Post-Stabilization Management

Once the patient begins to improve:

• Transition to oral hydrocortisone when able to tolerate oral intake
• Double the usual maintenance dose for 24-48 hours 2, 1
• Gradually taper to maintenance dose over several days 1
• Add fludrocortisone 0.05-0.1 mg daily once oral medications are tolerated (for primary adrenal insufficiency) 1, 5

Maintenance Therapy After Crisis Resolution

• Hydrocortisone 15-25 mg daily in divided doses (typically 2-3 times per day) 1
• Fludrocortisone 0.05-0.1 mg daily for primary adrenal insufficiency 1, 5
• Regular monitoring of electrolytes, blood pressure, and clinical status 1

Identifying and Treating the Precipitating Cause

Common precipitating factors that must be identified and addressed include:

• Infections (especially gastrointestinal)
• Trauma
• Surgery
• Medication non-compliance
• Acute psychological or physical stress 3

Pitfalls and Caveats

1. Do not delay treatment - Waiting for confirmatory testing before initiating treatment can be fatal 1, 3

2. Watch for inadequate dosing - Insufficient hydrocortisone dosing during crisis can lead to continued deterioration 4

3. Beware of premature dose reduction - Reducing hydrocortisone too quickly can lead to recurrent crisis 4

4. Monitor for complications - Addisonian crisis can lead to cardiomyopathy and cardiogenic shock in severe cases 6

5. Recognize subtle presentations - Early signs like fatigue, nausea, muscle/joint pain, and hyperpigmentation may precede full crisis 7

6. Provide patient education - All patients need education on stress dosing protocols, emergency injectable steroids, and medical alert identification to prevent future crises 1

Addisonian crisis is a life-threatening emergency with significant mortality risk if not promptly recognized and treated. The cornerstone of management is immediate high-dose hydrocortisone administration, aggressive fluid resuscitation, and careful monitoring while addressing the underlying precipitating cause.