What is the management of an Addisonian crisis?

Management of Addisonian Crisis

Administer hydrocortisone 100 mg IV bolus immediately upon clinical suspicion without waiting for diagnostic confirmation, followed by aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour. 1, 2

Immediate Emergency Treatment

Initial Bolus and Fluid Resuscitation

• Give hydrocortisone 100 mg IV bolus as soon as Addisonian crisis is suspected – this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect, eliminating the need for separate fludrocortisone during acute management 1, 3
• Draw blood for cortisol, ACTH, electrolytes, creatinine, and glucose before treatment begins, but never delay therapy waiting for laboratory results 1, 3
• Initiate aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour 1, 2
• Continue with 3-4 liters total of isotonic saline (or 5% dextrose in isotonic saline) over the following 24-48 hours 1, 2, 3

Ongoing Glucocorticoid Administration

• Continue hydrocortisone 100-300 mg per day, either as:
  • Continuous IV infusion of 200 mg/24 hours (preferred by most guidelines) 1, 3, OR
  • Divided doses of 100 mg IV/IM every 6-8 hours 1, 2
• Do not add fludrocortisone during acute crisis – high-dose hydrocortisone provides adequate mineralocorticoid activity 3, 4

Monitoring and Supportive Care

Hemodynamic and Laboratory Monitoring

• Monitor hemodynamic parameters frequently to guide fluid management and avoid fluid overload 1, 2, 3
• Check serum electrolytes frequently, as hyponatremia occurs in ~90% of cases and hyperkalemia in ~50% 2, 3
• Monitor blood glucose levels, especially in pediatric patients who are more vulnerable to hypoglycemia 3

Additional Supportive Measures

• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension 1, 3
• Provide prophylaxis for gastric stress ulcers 1
• Consider low-dose heparin prophylaxis depending on severity of illness 1
• Identify and treat precipitating causes (infection, trauma, surgery, gastroenteritis) with appropriate antimicrobial therapy or other interventions 1, 2

Transition to Maintenance Therapy

Tapering Protocol

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness permits and 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 1, 3
• For uncomplicated recovery, double the regular oral replacement dose of hydrocortisone for 48 hours 1
• For major surgery or complicated recovery, continue doubled doses for up to a week before resuming maintenance dose 1

Standard Maintenance Dosing

• Transition to hydrocortisone 15-25 mg daily divided into 2-3 doses 3
• Fludrocortisone 0.1 mg daily (range 0.1 mg three times weekly to 0.2 mg daily) for primary adrenal insufficiency 4

Prevention of Future Crises

Patient Education (Critical for Preventing Mortality)

• Teach patients to double or triple oral glucocorticoid doses during minor illness (fever, gastroenteritis, infections) 2, 5, 3
• Instruct patients to use parenteral hydrocortisone during severe illness or inability to take oral medications 2, 5, 3
• Emphasize that even mild gastrointestinal upset may precipitate crisis as patients cannot absorb oral medication when they need it most 3

Emergency Preparedness

• Provide emergency supplies including injectable hydrocortisone for home use 1, 2, 5
• Ensure patients wear medical alert jewelry and carry emergency steroid cards 1, 2, 5
• Arrange early endocrinology consultation for ongoing management and education 3

Identifying Risk Factors for Recurrent Crises

• Evaluate for chronic under-replacement with fludrocortisone combined with low salt consumption 1, 3
• Investigate poor compliance and underlying psychiatric disorders in patients with recurrent crises 1, 3
• Review medications that accelerate cortisol clearance (may require dose adjustments) 3

Critical Clinical Pitfalls to Avoid

• Never delay treatment to obtain diagnostic confirmation – mortality increases with delayed intervention 1, 3
• Never start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies, as this can trigger adrenal crisis 3
• Do not rely on absence of hyperkalemia to exclude crisis – it is present in only 50% of cases 3
• Recognize that 8.6% of adrenal crises occur due to medication errors and omissions during hospital stays 1
• Be aware that patients with comorbidities (especially asthma and diabetes) are more vulnerable to crisis 1

Special Populations

Pediatric Patients

• Initial fluid bolus: 10-20 mL/kg (maximum 1,000 mL) normal saline 3
• Hydrocortisone dosing based on age and body weight 3
• More frequent blood glucose monitoring required 3

Obstetric Patients

• Administer hydrocortisone 100 mg at onset of labor 2, 6
• Continue with 200 mg/24 hours IV infusion or 50 mg IM every 6 hours until after delivery 3, 6
• Fludrocortisone dose may need to be increased during third trimester 6