What is the treatment for an Addisonian crisis?

Treatment of Addisonian Crisis

Immediately administer hydrocortisone 100 mg IV bolus without waiting for diagnostic confirmation, and simultaneously begin aggressive fluid resuscitation with 0.9% saline 1 liter over the first hour. 1, 2, 3

Immediate Emergency Management (First Hour)

The cornerstone of treatment is rapid glucocorticoid and volume replacement, as delayed intervention increases mortality. 1, 2, 3

• Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this dose saturates mineralocorticoid receptors and eliminates the need for separate fludrocortisone during acute crisis 1, 2, 3

• Infuse 0.9% isotonic saline 1 liter over the first hour to address severe volume depletion and hypotension 1, 2, 3

• Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before treatment begins, but never delay therapy waiting for results 2, 3

• Monitor hemodynamic parameters frequently to guide ongoing resuscitation 1, 2

Critical Pitfall to Avoid

Treatment must never be postponed for diagnostic procedures when adrenal crisis is suspected—the diagnosis can always be established after treatment has been initiated, but mortality increases with delayed intervention. 4, 3

Ongoing Management (First 24-48 Hours)

• Continue hydrocortisone 100-300 mg per day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1, 2, 3

• Maintain isotonic saline infusion for 24-48 hours, administering a total of 3-4 liters of 0.9% saline or 5% dextrose in isotonic saline, adjusting based on hemodynamic response 1, 2, 3

• Monitor serum electrolytes frequently to guide fluid management and avoid complications 2, 3

• Do not add separate mineralocorticoid (fludrocortisone) during acute crisis, as high-dose hydrocortisone provides adequate mineralocorticoid activity 3

• Identify and treat precipitating causes such as infection, trauma, or gastrointestinal illness with appropriate antimicrobial therapy or other interventions 1, 2, 3

Additional Supportive Care

• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction 2, 3

• Provide gastric stress ulcer prophylaxis and consider low-dose heparin depending on severity of intercurrent illness 2, 3

• Treat hypoglycemia if present with dextrose-containing fluids, particularly important in pediatric patients 3

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness resolves and the patient can tolerate oral medications 1, 2, 3

• Restart fludrocortisone when hydrocortisone dose falls below 50 mg per day, as lower doses no longer provide adequate mineralocorticoid effect 4

• Transition to maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses, with preference for short-acting hydrocortisone over longer-acting agents 3

• Standard maintenance fludrocortisone dosing is 0.1 mg daily (range 0.1 mg three times weekly to 0.2 mg daily), typically combined with hydrocortisone 10-30 mg daily in divided doses 5

Prevention of Future Crises

Patient education is paramount to preventing recurrent crises and unnecessary deaths. 4, 1, 2

• Teach patients to double or triple oral glucocorticoid doses during minor illness (fever, gastrointestinal symptoms, infections) 1, 2

• Instruct patients to use parenteral hydrocortisone during severe illness, vomiting, or inability to take oral medications 1, 2, 3

• Ensure patients have emergency supplies including injectable hydrocortisone and know how to self-administer or have family members trained 1, 2, 6

• Provide medical alert jewelry and emergency steroid card to trigger appropriate treatment by emergency medical personnel 1, 2, 3

• Evaluate for chronic under-replacement with mineralocorticoid and low salt consumption as causes of recurrent crises 4

• Investigate poor compliance and underlying psychiatric disorders in patients with recurrent crises 4, 3

Common Precipitating Factors to Emphasize

The most common trigger is gastrointestinal illness with vomiting/diarrhea, as patients cannot absorb oral medication when they need it most. 2, 3, 7 Other triggers include infections, surgical procedures without adequate steroid coverage, physical trauma, myocardial infarction, and severe allergic reactions. 1, 2, 3