What is the treatment for an Addisonian crisis?

Treatment of Addisonian Crisis

Immediate treatment of an Addisonian crisis requires intravenous hydrocortisone 100 mg bolus followed by fluid resuscitation with 0.9% saline and continued glucocorticoid administration. 1, 2, 3

Emergency Management Algorithm

• Administer hydrocortisone 100 mg IV bolus immediately without delay for diagnostic procedures 1, 2, 3
• Begin fluid resuscitation with 0.9% saline at 1 L/hour initially 1, 2
• Continue with 3-4 L of isotonic saline over 24-48 hours with frequent hemodynamic monitoring 1, 2
• Maintain glucocorticoid administration with hydrocortisone 100-300 mg/day as either:
  • Continuous IV infusion, or
  • Divided IV/IM boluses every 6 hours 1, 2, 3
• Draw blood samples for cortisol, ACTH, electrolytes, creatinine, urea, glucose, and tests for precipitating causes (but don't delay treatment) 1, 4
• Identify and treat the underlying precipitating cause (infection, trauma, etc.) 1, 2
• Consider ICU/high-dependency unit admission for severe cases 1
• Consider prophylaxis for gastric stress ulcers and low-dose heparin in critically ill patients 1

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days once the patient is stabilized 1, 3
• If recovery is uncomplicated, transition to oral maintenance therapy by doubling the regular oral replacement dose of hydrocortisone for 48 hours 1
• For major surgery or complicated recovery, continue doubled dose for up to a week before resuming maintenance dose 1, 3
• Resume fludrocortisone (mineralocorticoid) when hydrocortisone dose falls below 50 mg/day 1
• Standard maintenance therapy includes fludrocortisone 0.1 mg daily (range 0.05-0.2 mg) 5

Common Precipitating Factors

• Gastrointestinal illness with vomiting/diarrhea 2, 6
• Infections 2, 6
• Surgical procedures without adequate steroid coverage 2, 6
• Physical injuries or trauma 2, 6
• Emotional distress 1

Prevention of Future Crises

• Patient education on stress dosing during illness or stress 1, 2
• Instruct patients to double or triple their glucocorticoid dose during minor illness 2, 3
• Ensure patients have emergency supplies including injectable hydrocortisone 2, 3
• Recommend medical identification (medical alert jewelry and emergency steroid card) 2, 3
• Schedule annual follow-up with assessment of health, weight, blood pressure, and electrolytes 1
• Monitor for development of other autoimmune disorders, particularly hypothyroidism 1

Important Clinical Considerations

• Addisonian crisis is life-threatening with significant mortality risk if treatment is delayed or inadequate 6
• Laboratory findings typically include hyponatremia, hyperkalemia, hypoglycemia, and prerenal renal failure 1, 4
• Neurological manifestations may include confusion, loss of consciousness, and coma 1, 4
• Patients with comorbidities, especially asthma and diabetes, are more vulnerable to adrenal crisis 1
• Patients with mineralocorticoid or vasopressin dependency are less stable than those with secondary adrenal insufficiency 1

Early recognition and aggressive treatment are essential for reducing mortality in Addisonian crisis. The treatment should never be delayed for diagnostic procedures, as the diagnosis can be confirmed after stabilization of the patient 1, 4, 6.