Management of Addisonian Crisis

Emergency Management

The American College of Endocrinology recommends immediate administration of hydrocortisone 100 mg IV bolus, followed by aggressive fluid resuscitation with 0.9% saline, for patients suspected of having an adrenal crisis 1
The Endocrine Society suggests beginning fluid resuscitation with 0.9% saline 1L over the first hour, followed by 3-4L over 24-48 hours with frequent hemodynamic monitoring 1
Continuous glucocorticoid administration with hydrocortisone 100-300 mg/day is recommended, either as continuous IV infusion or divided IV/IM boluses every 6 hours, according to the American Association of Clinical Endocrinologists 1
Evaluation for precipitating causes of crisis, such as infection, trauma, or surgery, is crucial, as stated by the Journal of Clinical Oncology 2

Hyperpigmentation of skin is a classic sign of primary adrenal insufficiency due to elevated adrenocorticotropic hormone levels, as noted by the Journal of Internal Medicine 3, 4
Hypotension and dehydration are cardinal manifestations of adrenal crisis requiring immediate intervention, according to the American College of Endocrinology 1

Tapering parenteral glucocorticoids over 1-3 days to oral maintenance therapy once the patient is stabilized is recommended by the American Association of Clinical Endocrinologists 1, 5
For maintenance therapy, hydrocortisone is the preferred glucocorticoid at a total daily dose of 15-25 mg divided into 2-3 doses, as suggested by the Endocrine Society 5

Comprehensive patient education on stress dosing during illness or stress is essential, as stated by the Journal of Internal Medicine and the American College of Endocrinology 3, 5
Instructing patients to double or triple their glucocorticoid dose during minor illness and to use parenteral hydrocortisone during severe illness is recommended by the American Association of Clinical Endocrinologists 1, 5
Ensuring patients have emergency supplies, including injectable hydrocortisone, and recommending medical identification, such as medical alert jewelry and emergency steroid card, is crucial, as noted by the Journal of Internal Medicine and the American College of Endocrinology 1, 3