What is the treatment for an Addison's disease crisis?

Treatment of Addison's Disease Crisis in the Emergency Department

Immediate treatment of an Addison's disease crisis requires intravenous hydrocortisone 100 mg bolus followed by 100 mg every 6-8 hours until recovery, along with rapid isotonic saline infusion at an initial rate of 1 L/hour until hemodynamic improvement. 1, 2

Emergency Management Algorithm

1. Initial Resuscitation (First Hour)

   • Administer hydrocortisone 100 mg IV/IM bolus immediately without delay 1, 2
   • Begin fluid resuscitation with 0.9% sodium chloride solution at 1 L/hour initially 1, 2
   • Secure blood samples for cortisol and ACTH measurement if possible, but never delay treatment for diagnostic procedures 1, 2
   • Monitor vital signs, including blood pressure and heart rate 2

2. Ongoing Management (Next 24-48 Hours)

   • Continue hydrocortisone 100 mg IV/IM every 6-8 hours until clinical improvement 1, 2
   • Adjust fluid administration based on hemodynamic response, typically 3-4 L over 24-48 hours 2
   • Investigate and treat the underlying precipitant (e.g., infection, trauma) 1
   • Monitor electrolytes, glucose, and renal function 2

3. Laboratory Assessment

   • Check serum electrolytes (expect hyponatremia, hyperkalemia) 2
   • Measure blood glucose (hypoglycemia may be present) 2
   • Assess renal function (creatinine, urea) 2
   • Perform tests to identify precipitating causes (e.g., cultures if infection suspected) 2

4. Transition to Maintenance Therapy

   • Once stabilized, taper parenteral glucocorticoids over 1-3 days 2
   • Transition to oral maintenance therapy: hydrocortisone 15-25 mg daily in divided doses 1
   • Add fludrocortisone 0.1 mg daily once oral medications are tolerated 3

Clinical Presentation and Recognition

• Common symptoms and signs of adrenal crisis include:
  • Severe weakness, fatigue, and malaise 4, 5
  • Nausea, vomiting, and abdominal pain 2, 4
  • Hypotension and shock 2, 4
  • Dehydration and electrolyte abnormalities 2
  • Altered mental status, confusion, or coma in severe cases 2

Common Precipitating Factors

• Gastrointestinal illness with vomiting/diarrhea (most common trigger) 2, 6
• Infections of any kind 2, 4
• Surgery without adequate steroid coverage 2
• Physical trauma or severe psychological stress 2, 4
• Abrupt discontinuation of glucocorticoid therapy 6

Prevention of Future Crises

• Patient education is crucial - provide verbal and written instructions on stress dosing 2, 6
• Recommend medical alert jewelry and emergency steroid cards 2
• Prescribe emergency injectable hydrocortisone kit and teach proper administration 2, 6
• Establish stress dosing protocols: double oral glucocorticoid dose during minor illness, use parenteral hydrocortisone for severe illness 2

Follow-up After Crisis

• Identify and address the precipitating cause 2
• Review the patient's understanding of stress dosing and self-management 2
• Ensure adequate supplies of maintenance medications and emergency supplies 2
• Schedule regular follow-up to monitor health, weight, blood pressure, and electrolytes 1, 2

Common Pitfalls to Avoid

• Delaying treatment while waiting for diagnostic confirmation - treatment should never be delayed 1, 2
• Inadequate fluid resuscitation - hypotension in adrenal crisis is often volume-dependent 1, 2
• Insufficient glucocorticoid dosing - underdosing can lead to persistent crisis 4
• Failure to identify and treat the underlying precipitant 1
• Inadequate patient education on prevention of future crises 2, 6