What is the treatment for adrenal crisis (Addisonian crisis)?

From the Guidelines

Adrenal crisis is a life-threatening medical emergency requiring immediate treatment with hydrocortisone 100mg IV bolus, followed by 200mg over 24 hours as a continuous infusion, as recommended by the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Key Considerations

• The condition presents with severe hypotension, nausea, vomiting, abdominal pain, confusion, and sometimes fever, and occurs due to insufficient cortisol production during times of physiological stress, typically in patients with adrenal insufficiency.
• Simultaneously, administer 1-2 liters of normal saline rapidly to restore blood volume and correct hypotension.
• After stabilization, transition to oral hydrocortisone at a dose that is double the patient's usual maintenance dose, with dose adjustments based on clinical response.
• Patients should be monitored closely for blood pressure normalization, electrolyte balance (particularly sodium and potassium), and glucose levels.
• Education about their condition, stress dosing protocols during illness, and medical alert identification is crucial for preventing future crises, as emphasized in the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1.

Treatment and Management

• The treatment guidelines for adrenal crisis are outlined in Table 7 of the consensus statement, which recommends rapid intravenous administration of hydrocortisone and isotonic saline, as well as treatment of precipitating conditions 1.
• Parenteral glucocorticoids should be tapered over 1-3 days to oral, if the precipitating or complicating illness permits.
• The importance of not delaying treatment by diagnostic procedures is highlighted in the guidelines, and immediate initiation of therapy is recommended 1.

Prevention of Future Crises

• Patients should understand the importance of doubling or tripling their maintenance steroid dose during minor illnesses and seeking immediate medical attention during severe illness to prevent future crises, as advised in the guidelines 1.
• Regular follow-up and assessment of health and well-being, measurement of weight, blood pressure, and serum electrolytes, as well as occasional monitoring for the development of new autoimmune disorders, are essential for patients with adrenal insufficiency 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. Patients should be continually monitored for signs that indicate dosage adjustment is necessary, such as remission or exacerbations of the disease and stress (surgery, infection, trauma) In Addison’s disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects.

The management of adrenal crisis is not directly addressed in the provided drug labels. However, it can be inferred that patients with Addison's disease, who are at risk of adrenal crisis, should be continually monitored for signs of stress, such as surgery, infection, or trauma, which may require dosage adjustment of their medication regimen, including fludrocortisone and glucocorticoids like hydrocortisone or cortisone 2.

• Key points:
  • Monitor patients for signs of stress that may indicate dosage adjustment is necessary
  • Combination therapy with fludrocortisone and a glucocorticoid may be used to approximate normal adrenal activity
  • Dosage adjustment may be necessary in the event of stress, such as surgery, infection, or trauma
  • The provided drug labels do not directly address the management of adrenal crisis, and therefore, no specific conclusion can be drawn regarding the treatment of adrenal crisis with these medications 2.

From the Research

Adrenal Crisis Overview

• Adrenal crisis is a life-threatening emergency that contributes to excess mortality in patients with adrenal insufficiency 3, 4.
• The incidence of adrenal crisis is estimated to be 5-10 crises per 100 patient years, with a mortality rate of 0.5 per 100 patient years 3.

Causes and Precipitating Factors

• Infections are a major precipitating cause of adrenal crisis, leading to impaired well-being, hypotension, nausea, vomiting, and fever 3.
• Other precipitating factors include emotional distress, surgery, cessation or reduction in glucocorticoid doses, pituitary infarction, and surgical cure of endogenous Cushing's syndrome 4.

Treatment and Management

• Treatment of adrenal crisis involves rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg over 24 hours as continuous infusion) and 0.9% saline 3, 4.
• Prevention of adrenal crisis requires appropriate hydrocortisone dose adjustments to stressful medical procedures and other stressful events, as well as patient education on sick-day rules and hydrocortisone parenteral self-administration 3, 4.

Patient Education and Support

• Patient education is a key factor in preventing adrenal crisis, but current education concepts are not sufficiently effective 3.
• Improved education strategies are needed, and patients should be provided with an emergency card and an emergency kit for parenteral hydrocortisone self-administration 3.
• Collaboration with medical specialist societies and patient support associations is necessary to promote adequate preventive education in patients at risk for secondary adrenal insufficiency 4.