How to manage hypotension in a patient with Addison's disease?

Management of Hypotension in Addison's Disease

Hypotension in Addison's disease requires immediate intravenous hydrocortisone 100 mg and aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour, as high-dose hydrocortisone provides both glucocorticoid and mineralocorticoid effects needed to restore blood pressure. 1

Acute Crisis Management (Severe Hypotension/Shock)

Immediate Actions (Do Not Delay for Diagnostic Confirmation)

• Administer hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this dose saturates mineralocorticoid receptors and provides the necessary aldosterone-like effect 1
• Initiate aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour to address severe volume depletion 1
• Draw blood for cortisol, ACTH, electrolytes, creatinine, and glucose before treatment begins, but never delay therapy waiting for results 1

Ongoing Acute Management

• Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion (or 50 mg IV/IM every 6 hours as an alternative) 1
• Maintain slower isotonic saline infusion for 24-48 hours with frequent hemodynamic monitoring to avoid fluid overload 1
• Administer 3-4 liters total of isotonic saline or 5% dextrose in isotonic saline over 24 hours, adjusting based on hemodynamic response 1
• Do not add separate fludrocortisone during acute crisis—high-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity 1
• Monitor serum electrolytes frequently to guide fluid management 1

Critical Pitfall to Avoid

Never use dexamethasone as the primary glucocorticoid in primary adrenal insufficiency—it lacks mineralocorticoid activity and will not correct the hypotension 1

Chronic Hypotension Management (Stable Patients)

Optimization of Replacement Therapy

• Ensure adequate mineralocorticoid replacement with fludrocortisone 0.05-0.20 mg once daily (usual dose 0.1 mg daily) 2, 3
• Provide glucocorticoid replacement with hydrocortisone 15-25 mg daily divided into 2-3 doses, preferably weight-adjusted 1, 3
• Monitor for orthostatic hypotension as an early warning sign—check blood pressure in both supine and standing positions, as orthostatic changes occur before supine hypotension develops 1

Addressing Persistent Hypotension

When hypotension persists despite standard replacement:

• Evaluate for chronic under-replacement with fludrocortisone combined with low salt consumption 1
• Assess medication compliance, particularly with mineralocorticoid therapy 1
• Consider increasing fludrocortisone dose up to 0.2 mg daily if signs of mineralocorticoid deficiency persist 2
• Ensure adequate salt intake—sodium loss in urine from aldosterone deficiency requires dietary compensation 1

Special Consideration for Hypertensive Patients

If a patient with Addison's disease develops hypertension (uncommon but possible):

• First optimize glucocorticoid replacement and consider dose reduction if excessive 4
• Review fludrocortisone dose and reduce if clinical/biochemical signs of mineralocorticoid excess are present 4
• If renin is elevated or upper-normal range without signs of mineralocorticoid excess, use ACE inhibitors or angiotensin II receptor antagonists while maintaining fludrocortisone dose 4
• Avoid diuretics in stable Addison's disease with hypertension 4

Transition from Acute to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness resolves and oral medications are tolerated 1
• Restart fludrocortisone when hydrocortisone dose falls below 50 mg per day, as lower doses no longer provide adequate mineralocorticoid effect 1
• Double the usual oral hydrocortisone dose for 48 hours after resuming oral intake following uncomplicated recovery 1

Prevention of Future Hypotensive Episodes

• Educate patients to double or triple oral glucocorticoid doses during minor illness (fever, vomiting, diarrhea) 1
• Teach patients to use parenteral hydrocortisone during severe illness or inability to take oral medications 1
• Provide medical alert jewelry and emergency steroid card to trigger stress-dose corticosteroids by emergency personnel 1
• Even mild gastrointestinal upset can precipitate crisis as patients cannot absorb oral medication when they need it most 1