What is the dosage for emergency Addison’s crisis treatment after initial administration of 125mg of hydrocortisone (corticosteroid)?

Emergency Addison's Crisis Treatment After Initial 125mg Hydrocortisone

After the initial 125mg hydrocortisone bolus, continue with 100mg hydrocortisone IV every 6 hours (total 400mg/24 hours) or 200mg/24 hours as continuous IV infusion, along with aggressive 0.9% saline resuscitation. 1, 2, 3

Immediate Continuation Protocol

The standard approach following the initial emergency bolus is to administer hydrocortisone 100mg IV every 6 hours for the first 24-48 hours, which provides a total daily dose of 400mg. 1 Alternatively, 200-300mg hydrocortisone can be given as a continuous IV infusion over 24 hours, which may provide more stable cortisol levels and avoid glucose spikes. 2, 3

• The FDA-approved dosing for acute life-threatening situations states that the initial dose of 100-500mg may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition. 4
• The Endocrine Society recommends continued hydrocortisone therapy at 200mg over 24 hours as continuous infusion following the initial 100mg bolus. 3

Concurrent Fluid Resuscitation

Aggressive fluid resuscitation with 0.9% isotonic saline is equally critical, with at least 1 liter administered within the first hour, followed by continued crystalloid infusion guided by hemodynamic response. 2, 3

• The Society of Critical Care Medicine emphasizes that fluid resuscitation must occur simultaneously with hydrocortisone administration, as both are essential for reversing shock. 2
• Monitor serum electrolytes frequently to guide ongoing fluid management, particularly watching for hyponatremia and hyperkalemia correction. 2

Duration and Tapering Strategy

High-dose hydrocortisone therapy should be continued only until the patient's condition has stabilized, usually not beyond 48-72 hours. 4

• Once the patient is hemodynamically stable and able to tolerate oral intake, transition to oral hydrocortisone at 2-3 times the maintenance dose (typically 30-75mg daily in divided doses). 1
• The American College of Obstetricians and Gynecologists protocol for labor management provides a similar framework: 100mg hydrocortisone bolus repeated every 6 hours as needed, then doubled oral dose for 24-48 hours postpartum before gradual reduction. 1
• Taper the dose gradually over several days as the precipitating stressor resolves, eventually returning to maintenance dosing of 15-25mg daily. 1

Critical Monitoring Parameters

Do not delay or withhold treatment while waiting for laboratory confirmation—adrenal crisis is a clinical diagnosis requiring immediate intervention. 2, 3

• Monitor blood pressure, heart rate, and mental status continuously during the acute phase. 2
• Check serum sodium, potassium, and glucose every 4-6 hours initially, as hypernatremia may develop with prolonged high-dose hydrocortisone therapy beyond 48-72 hours. 5, 4
• If hypernatremia occurs with therapy beyond 72 hours, consider switching to methylprednisolone sodium succinate, which causes less sodium retention. 5

Common Pitfalls to Avoid

Never use continuous infusion as the sole initial treatment—always start with an immediate IV bolus of 100mg hydrocortisone to achieve rapid cortisol levels. 2, 3

• The initial 125mg dose mentioned in the question is appropriate (within the 100-500mg range), but must be followed by continued dosing, not given as a single dose. 4
• Do not attempt to use vasopressors alone for refractory hypotension—hydrocortisone is the definitive treatment and vasopressors will be ineffective without adequate glucocorticoid replacement. 2
• Avoid abrupt cessation of high-dose therapy; always taper gradually to prevent rebound crisis. 5

Special Considerations for Primary vs Secondary Adrenal Insufficiency

In primary adrenal insufficiency (Addison's disease), once the acute crisis resolves and oral intake resumes, fludrocortisone 0.05-0.1mg daily must be added for mineralocorticoid replacement. 1, 2

• During acute crisis management with high-dose hydrocortisone (≥100mg), the mineralocorticoid activity of hydrocortisone is sufficient, so fludrocortisone is not needed acutely. 1
• Secondary adrenal insufficiency does not require mineralocorticoid replacement as the renin-angiotensin-aldosterone system remains intact. 6