What is the management of suspected adrenal insufficiency (Addisonian crisis)?

From the Guidelines

For suspected adrenal insufficiency, immediately administer hydrocortisone 100 mg intravenously as a bolus, followed by a continuous infusion of hydrocortisone at 200 mg/24h, until the patient can take double their usual oral glucocorticoid dose by mouth, as recommended by the most recent guidelines 1.

Key Considerations

• The management of suspected adrenal insufficiency prioritizes prompt evaluation and treatment to prevent life-threatening complications, focusing on morbidity, mortality, and quality of life outcomes.
• The use of hydrocortisone is preferred due to its mineralocorticoid activity, which is essential for patients with primary adrenal insufficiency, as highlighted in the guidelines 1.
• Fluid resuscitation with normal saline is crucial to correct hypotension and electrolyte abnormalities, particularly hyponatremia and hyperkalemia, as emphasized in the management of acute adrenal insufficiency 1.
• Patients should be educated about stress dosing, the use of emergency steroid injectables, and the importance of carrying a steroid emergency card and wearing medical identification, as recommended in the guidelines for managing immune-related adverse events 1.

Treatment Approach

• The initial treatment with hydrocortisone should be followed by a continuous infusion, which can be adjusted based on the patient's response and clinical judgment, as suggested in the guidelines 1.
• Once the patient is stable, maintenance therapy with oral hydrocortisone or prednisone should be initiated, with doses adjusted according to the patient's needs and response, as recommended in the guidelines 1.
• Patients with primary adrenal insufficiency require mineralocorticoid replacement with fludrocortisone, which should be adjusted based on the patient's volume status, sodium levels, and renin response, as emphasized in the guidelines 1.

Education and Follow-up

• Patient education is critical to prevent adrenal crisis, and patients should be instructed on stress dosing, recognition of adrenal insufficiency symptoms, and the importance of seeking medical attention promptly, as recommended in the guidelines 1.
• Regular follow-up with an endocrinologist is essential to monitor the patient's response to treatment, adjust doses as needed, and prevent long-term complications, as suggested in the guidelines 1.

From the FDA Drug Label

In the event of serious trauma or illness, in patients with known adrenal insufficiency or when adrenocortical reserve is doubtful Shock unresponsive to conventional therapy if adrenocortical insufficiency exists or is suspected. Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy, mineralocorticoid supplementation is of particular importance) Acute adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; mineralocorticoid supplementation may be necessary, particularly when synthetic analogs are used).

The management of suspected adrenal insufficiency (Addisonian crisis) involves the use of hydrocortisone or cortisone as the drug of choice, with possible mineralocorticoid supplementation. In cases of shock unresponsive to conventional therapy, adrenocortical insufficiency should be suspected and treated accordingly.

• Key points:
  • Use hydrocortisone or cortisone as first-line treatment.
  • Consider mineralocorticoid supplementation as needed.
  • Be aware of the potential for adrenocortical insufficiency in patients with serious trauma or illness. 2

From the Research

Management of Suspected Adrenal Insufficiency (Addisonian Crisis)

The management of suspected adrenal insufficiency, also known as Addisonian crisis, involves several key components:

• Hydrocortisone replacement: The mainstay of treatment in adrenal crisis is hydrocortisone, which can be administered intravenously 3.
• Intravenous fluid and glucose repletion: Patients with adrenal insufficiency often require intravenous fluid and glucose repletion to manage hypotension and hypoglycemia 3.
• Treatment of underlying acute trigger: Identifying and treating the underlying cause of the adrenal crisis, such as infection or surgery, is crucial 3.
• Dose adjustments: Patients with known adrenal insufficiency require dose adjustments during times of stress, such as illness or surgery, to prevent adrenal crisis 4, 5.
• Education and monitoring: Patients and their families should be educated on recognizing the signs of adrenal crisis, how to respond to an impending crisis, and the importance of regular monitoring and follow-up 4, 5.

Glucocorticoid Replacement Therapy

Glucocorticoid replacement therapy is vital in all cases of adrenal insufficiency:

• Hydrocortisone dosing: The recommended dosing of hydrocortisone varies, but typically ranges from 15-25 mg/day in divided doses 4.
• Individualized dosing: Dosing should be individualized based on the patient's response to treatment and adjusted as needed 4, 5.
• Mineralocorticoid replacement: Patients with primary adrenal insufficiency may also require mineralocorticoid replacement therapy, such as fludrocortisone 4, 5.

Special Considerations

Certain patient populations, such as children, may require special consideration:

• Pediatric patients: Children with primary adrenal insufficiency require glucocorticoid replacement therapy with hydrocortisone, and may also require mineralocorticoid replacement therapy 5.
• Monitoring and follow-up: Regular monitoring and follow-up are crucial in pediatric patients to ensure adequate treatment and prevent complications 5.