What is the treatment for an Addisonian crisis?

Treatment of Addisonian Crisis

Immediately administer hydrocortisone 100 mg intravenous bolus and start aggressive fluid resuscitation with 0.9% normal saline at 1 liter over the first hour—treatment must never be delayed for diagnostic confirmation when adrenal crisis is suspected. 1, 2, 3

Immediate Emergency Management (First Hour)

Draw blood samples before treatment begins, but do not wait for results:

• Obtain cortisol, ACTH, electrolytes (sodium, potassium), glucose, creatinine, and BUN 1, 2
• Treatment takes absolute priority over diagnostic confirmation 1, 3

Glucocorticoid administration:

• Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion 1, 2, 3
• This high dose saturates 11β-hydroxysteroid dehydrogenase type 2, providing necessary mineralocorticoid effect without requiring separate fludrocortisone 1

Fluid resuscitation:

• Infuse 0.9% isotonic saline at 1 liter over the first hour 1, 2
• Continue with 3-4 liters total over 24-48 hours, adjusting based on hemodynamic response 1, 2
• 5% dextrose in isotonic saline can be used if hypoglycemia is present 1, 2

Ongoing Management (24-48 Hours)

Continued glucocorticoid therapy:

• Administer hydrocortisone 200 mg per 24 hours as continuous IV infusion (preferred for safety) 4, 1, 2
• Alternative: hydrocortisone 50 mg IV or IM every 6 hours 1, 2
• Continue parenteral therapy until the patient can tolerate oral medications and the precipitating illness is controlled 1, 2

Monitoring requirements:

• Frequent hemodynamic monitoring to avoid fluid overload 1
• Serial electrolyte checks to guide fluid management 1
• Blood glucose monitoring, especially in children who are more vulnerable to hypoglycemia 4

Do NOT add separate mineralocorticoid during acute crisis:

• High-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity 1
• Fludrocortisone is only restarted when hydrocortisone dose falls below 50 mg per day 1
• Dexamethasone is inadequate for primary adrenal insufficiency as it lacks mineralocorticoid activity 4

Transition to Maintenance Therapy

Tapering parenteral glucocorticoids:

• Taper over 1-3 days once precipitating illness permits oral intake 1, 2
• For uncomplicated recovery: double the usual oral hydrocortisone dose for 48 hours 4, 2
• For major surgery or complicated recovery: continue doubled doses for up to one week 4, 2

Resuming mineralocorticoid replacement:

• Restart fludrocortisone 0.05-0.2 mg daily (typical dose 0.1 mg) when hydrocortisone falls below 50 mg per day 1, 5
• Fludrocortisone is administered in conjunction with maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses 1, 5

Critical Pitfalls to Avoid

Never delay treatment for diagnostic procedures:

• Mortality increases with delayed intervention 1, 3
• Even mild symptoms can rapidly progress to cardiovascular collapse 1, 6

Recognize that laboratory findings can be misleading:

• Hyperkalemia is present in only 50% of cases—its absence does not exclude adrenal crisis 1, 3
• Hyponatremia occurs in 90% but its absence should not prevent treatment if clinical suspicion is high 1, 3

Avoid medication errors in hospitalized patients:

• 8.6% of adrenal crises occur due to insufficient glucocorticoid medication during hospital stays 4
• Ward staff may dismiss patient warnings about under-replacement 4

Special Populations

Pediatric patients:

• Initial fluid bolus: 10-20 mL/kg (maximum 1,000 mL) normal saline 2
• Hydrocortisone dosing based on age and body weight with more frequent blood glucose monitoring 4
• Children are more vulnerable to hypoglycemia than adults 4

Obstetric patients:

• Hydrocortisone 100 mg at onset of labor 4
• Continue with either 200 mg per 24 hours IV infusion or 50 mg IM every 6 hours until after delivery 4

Supportive Care and Precipitating Cause Management

Additional interventions:

• Consider ICU admission for severe cases with persistent hypotension or end-organ dysfunction 1
• Provide gastric stress ulcer prophylaxis 1
• Consider low-dose heparin depending on severity of illness 1
• Treat underlying precipitating conditions (infections, trauma, etc.) with appropriate therapy 1, 3

Common precipitating factors to address:

• Gastrointestinal illness with vomiting/diarrhea (most common trigger) 1, 3
• Infections of any type 1, 3
• Surgical procedures without adequate steroid coverage 1, 3
• Physical trauma or myocardial infarction 1, 3

Prevention of Future Crises

Patient education is paramount:

• Teach patients to double or triple oral glucocorticoid doses during minor illness 1, 2
• Provide emergency injectable hydrocortisone supplies for severe illness when oral intake is impossible 1, 2
• Issue medical alert jewelry and steroid emergency card 1, 2
• Emphasize that even mild gastrointestinal upset can precipitate crisis when oral medications cannot be absorbed 1

Arrange endocrinology follow-up:

• Evaluate the precipitating cause of the crisis 1, 2
• Review patient understanding of stress dosing and self-management 2
• Assess for chronic under-replacement with mineralocorticoid or poor compliance 1