What is the management of an Addisonian crisis?

Management of Addisonian Crisis

An Addisonian crisis requires immediate treatment with hydrocortisone 100 mg IV bolus, followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours, along with rapid IV administration of isotonic saline. 1

Immediate Management

1. Glucocorticoid Replacement:

   • Initial dose: 100 mg hydrocortisone IV bolus 1
   • Maintenance: 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
   • Continue until the precipitating cause is resolved and the patient can resume oral medication 2

2. Fluid Resuscitation:

   • Rapid IV administration of isotonic saline to correct hypovolemia and hypotension 1
   • Address dehydration and electrolyte imbalances (hyponatremia, hyperkalemia) 2

3. Glucose Administration:

   • Administer glucose if hypoglycemia is present 3
   • Monitor blood glucose levels regularly

Monitoring During Crisis

• Vital signs (blood pressure, heart rate, respiratory rate)
• Electrolytes (sodium, potassium)
• Blood glucose
• Fluid balance
• Signs of improvement or deterioration

Transition to Maintenance Therapy

Once the patient is stabilized:

1. Oral Glucocorticoid Replacement:

   • Hydrocortisone 15-25 mg daily in divided doses (2/3 in morning, 1/3 in afternoon) 1
   • Weight-adjusted dosing is preferred 4

2. Mineralocorticoid Replacement:

   • Fludrocortisone 0.1 mg daily (range: 0.05-0.2 mg) 1, 5
   • Adjust based on blood pressure, electrolytes, and symptoms 1

Common Pitfalls and How to Avoid Them

• Delayed diagnosis: Consider adrenal crisis in patients with unexplained shock, especially with history of steroid use or adrenal insufficiency 1
• Insufficient dosing: Do not underdose glucocorticoids during crisis; higher doses are necessary 1
• Premature dose reduction: Reducing hydrocortisone too quickly can lead to recurrent cardiovascular insufficiency 3
• Inadequate fluid replacement: Aggressive volume therapy is essential 3
• Failure to identify and treat the precipitating cause: Infections (especially gastrointestinal), trauma, or psychological stress often trigger crises 2

Patient Education for Future Prevention

• Wear a medical alert bracelet/card 1
• Stress dosing education (when and how to increase medication during illness) 1
• Emergency injectable hydrocortisone kit and training 1, 2
• Regular follow-up with endocrinologists 1

Special Considerations

• Patients who have abruptly discontinued long-term glucocorticoid therapy are at risk for adrenal crisis 3
• Symptoms can develop rapidly within hours, even from a state of apparent health 2
• Mortality risk is significant if treatment is delayed or inadequate 2

Remember that an Addisonian crisis is a medical emergency requiring prompt recognition and aggressive treatment to prevent potentially fatal outcomes.