Addisonian crisis

AKA adrenal crisis. An adrenal insufficiency emergency.

Symptoms: mental status changes (confusion, lethargy, or agitation), muscle weakness.

Signs: postural hypotension or shock, hyperthermia (as high as 105 °F, 45.6 C)

Labs Hyponatremia, hyperkalemia, hypoglycemia.

Treatment of Addisonian crisis

If possible, draw serum for cortisol determination (do not wait for these results to institute therapy). Give fluids sufficient for dehydration and shock.

For “glucocorticoid emergency”

Drug info: Levothyroxine (Synthroid®)

Almost pure T4 (contains no T3 as most T3 is produced peripherally from T4). Dose required to prevent myxedema coma (not to achieve euthyroidism):

● Maintenance: ℞ 0.05 mg po q d

● when the patient has been hypothyroid: ℞ start at 0.05 mg po q d and increase by 0.025 mg every 2–3 weeks

For euthyroidism (approximate dose, follow levels and clinical evaluation):

● for most adults < 60 years of age: ℞ 0.18 mg/day

● for elderly patients: ℞ 0.12 mg/day

Drug info: Desiccated thyroid (e.g. Armour thyroid®)

Typical dose: ℞ 60 mg (1 grain) to 300 mg daily.

● hydrocortisone sodium succinate (Solu-Cortef®): 100 mg IV STAT and then 50 mg IV q 6 hrs AND

● cortisone acetate 75–100 mg IM STAT, and then 50–75 mg IM q 6 hrs

For “mineralocorticoid emergency”

Usually not necessary in secondary adrenal insufficiency (e.g. panhypopituitarism)

● desoxycorticosterone acetate (Doca®): 5 mg IM BID OR

● fludrocortisone (Florinef®): 0.05- 0.2 mg PO q d

✖ methylprednisolone is NOT recommended for emergency treatment.

Streetz-van der Werf C, Karges W, Blaum M, Kreitschmann-Andermahr I. Addisonian Crisis after Missed Diagnosis of Posttraumatic Hypopituitarism. J Clin Med. 2015 May 15;4(5):965-9. doi: 10.3390/jcm4050965. PubMed PMID: 26239458; PubMed Central PMCID: PMC4470209.