What is the recommended treatment for patients with influenza and Addison's disease?

Treatment of Influenza in Patients with Addison's Disease

Patients with Addison's disease who develop influenza require stress-dose corticosteroid supplementation in addition to standard influenza management with oseltamivir and supportive care. 1

Critical First Step: Stress-Dose Corticosteroids

The most important intervention is immediate stress-dose corticosteroid supplementation to prevent adrenal crisis. Patients with Addison's disease cannot mount an adequate cortisol response to the physiologic stress of acute infection, which can be life-threatening. While the provided guidelines do not explicitly address Addison's disease, this population falls under "patients unable to mount an adequate febrile response" who require special consideration. 1

• Double or triple the patient's usual glucocorticoid dose during febrile illness
• If the patient cannot tolerate oral intake due to nausea/vomiting, switch immediately to parenteral hydrocortisone (typically 100 mg IV every 6-8 hours for severe illness)
• Monitor for signs of adrenal crisis: hypotension, altered mental status, severe weakness, electrolyte abnormalities

Antiviral Therapy

Initiate oseltamivir 75 mg orally every 12 hours for 5 days if the patient presents within 48 hours of symptom onset with fever >38°C. 1, 2

• Patients with Addison's disease may not mount adequate fever despite severe illness, so consider oseltamivir even without documented fever if clinical suspicion is high 1
• If hospitalized or severely ill, oseltamivir may benefit even beyond 48 hours from symptom onset, particularly given the immunocompromised state from chronic corticosteroid therapy 1, 2
• Reduce dose to 75 mg once daily if creatinine clearance <30 mL/min 1

Antibiotic Management: Risk-Stratified Approach

Patients with Addison's disease are at high risk for complications and secondary bacterial infection due to chronic immunosuppression from corticosteroid therapy. 1

Without Pneumonia

• Do not routinely prescribe antibiotics for uncomplicated influenza without pneumonia 1, 2
• Add antibiotics immediately if worsening symptoms develop: recrudescent fever or increasing dyspnea 1, 2
• First-line oral therapy: co-amoxiclav or tetracycline 1, 2
• Alternative: macrolide (clarithromycin) or fluoroquinolone (levofloxacin, moxifloxacin) if penicillin-intolerant 1

Non-Severe Influenza-Related Pneumonia

• Oral co-amoxiclav or tetracycline as first-line therapy 1, 2
• If oral route contraindicated: IV co-amoxiclav or cefuroxime/cefotaxime 1

Severe Influenza-Related Pneumonia

• Immediate parenteral combination therapy within 4 hours of diagnosis: IV co-amoxiclav or 2nd/3rd generation cephalosporin (cefuroxime or cefotaxime) PLUS macrolide (clarithromycin or erythromycin) 1, 2
• This combination provides coverage for Streptococcus pneumoniae and Staphylococcus aureus, the most common bacterial superinfections 1

Monitoring Parameters

Monitor vital signs at least twice daily, more frequently if severe illness: 1

• Temperature, respiratory rate, pulse, blood pressure
• Mental status (critical for detecting adrenal crisis)
• Oxygen saturation and inspired oxygen concentration
• Electrolytes (sodium, potassium) to detect adrenal insufficiency

Use an Early Warning Score system for systematic monitoring 1

Critical Pitfalls to Avoid

Never delay stress-dose corticosteroids while awaiting laboratory confirmation of influenza. The risk of adrenal crisis far outweighs any theoretical concern about corticosteroid effects on viral replication.

Never assume normal fever response. Patients on chronic corticosteroids may have blunted fever despite severe infection, so maintain high clinical suspicion. 1

Never withhold antibiotics if bacterial superinfection is suspected. This population is particularly vulnerable to Staphylococcus aureus pneumonia, which carries high mortality. 1, 2

Never discharge with fewer than two unstable clinical factors: temperature >37.8°C, heart rate >100/min, respiratory rate >24/min, systolic BP <90 mmHg, oxygen saturation <90%, inability to maintain oral intake, or abnormal mental status. 1

Supportive Care

• Antipyretics for fever control (acetaminophen preferred) 2
• Aggressive hydration, particularly important given mineralocorticoid deficiency in Addison's disease
• Nutritional support in severe or prolonged illness 1
• Avoid aspirin if patient <16 years due to Reye's syndrome risk 2