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Adrenal Crisis: A Pharmacological Emergency

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Adrenal Crisis: A Pharmacological Emergency

A 45-year-old woman with a history of Addison's disease presents to the emergency department with a 2-day history of vomiting, diarrhea, and abdominal pain. She is on hydrocortisone 20 mg in the morning and 10 mg in the afternoon, and fludrocortisone 0.1 mg daily. She has not been able to take her medications for 2 days due to vomiting. On examination: BP 80/50 mmHg, HR 120, temperature 37.8°C, RR 22, SpO2 98% on room air. She is drowsy but oriented. Her skin is hyperpigmented, and mucous membranes are dry. Blood tests: sodium 128 mmol/L, potassium 5.8 mmol/L, glucose 3.2 mmol/L, cortisol 150 nmol/L (normal 200-700), ACTH elevated. ECG shows peaked T waves. The ED has hydrocortisone, fludrocortisone, 0.9% saline, 5% dextrose, calcium gluconate, and insulin available.

1. What is the diagnosis and what is the immediate management? Include specific drugs, doses, and routes. Explain the rationale for each intervention.

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Diagnosis: Adrenal crisis (acute adrenal insufficiency) precipitated by vomiting/diarrhea leading to inability to take oral steroids.

Immediate management:

  1. Hydrocortisone: Administer 100 mg IV bolus immediately, followed by 50-100 mg IV every 6 hours (or 200 mg/24h as continuous infusion). Hydrocortisone provides both glucocorticoid and mineralocorticoid activity. Do not wait for cortisol results.
  2. Fluid resuscitation: 0.9% saline 1 L IV over 1 hour (or faster if severe hypotension). Repeat as needed based on BP, urine output, and electrolytes. Avoid dextrose-containing fluids initially unless hypoglycemia is severe.
  3. Glucose: For hypoglycemia (glucose 3.2 mmol/L), give IV dextrose (e.g., 100 mL of 20% dextrose or 50 mL of 50% dextrose) and start a 5% dextrose infusion to maintain glucose >4 mmol/L.
  4. Hyperkalemia: Potassium 5.8 mmol/L with peaked T waves. Calcium gluconate 10% 10 mL IV to stabilize myocardium. Insulin 10 units with 25 g glucose (e.g., 50 mL 50% dextrose) to shift potassium intracellularly. Avoid potassium-containing fluids. Hydrocortisone will also help lower potassium.
  5. Fludrocortisone: Not needed acutely because hydrocortisone has mineralocorticoid effect at high doses. Start fludrocortisone 0.1 mg daily once stable and able to take oral meds.
  6. Treat precipitant: Investigate and treat the cause of vomiting/diarrhea (e.g., infection).
  7. Monitoring: Continuous cardiac monitoring, frequent BP, electrolytes, and glucose. Insert urinary catheter for urine output.

Rationale:

  • Hydrocortisone reverses glucocorticoid deficiency, improves vascular tone and cardiac contractility, and suppresses ACTH.
  • Saline corrects hypovolemia and hyponatremia.
  • Dextrose corrects hypoglycemia.
  • Calcium protects the heart from hyperkalemia; insulin shifts potassium into cells.
  • Fludrocortisone is not needed acutely due to high-dose hydrocortisone's mineralocorticoid effect.

2. After initial stabilization, the patient's BP improves to 110/70 mmHg, but her sodium is 130 mmol/L and potassium 4.5 mmol/L. She is now able to take oral fluids. How do you transition her to oral medications, and what education does she need? Discuss the pharmacology of hydrocortisone and fludrocortisone.

Read the worked answer

Transition to oral medications:

  • Taper hydrocortisone: Reduce IV hydrocortisone gradually over 24-48 hours to her maintenance oral dose (e.g., hydrocortisone 15-25 mg/day in divided doses). A common regimen is 10 mg on waking, 5 mg at lunch, and 5 mg at 4 pm (to mimic circadian rhythm). Avoid giving late in the evening to prevent insomnia.
  • Start fludrocortisone: Once the hydrocortisone dose is reduced below 50 mg/day (as mineralocorticoid effect diminishes), start fludrocortisone 0.1 mg daily. Monitor BP, sodium, and potassium. Adjust dose as needed (0.05-0.2 mg daily).
  • Ensure adequate oral intake and monitor electrolytes.

Patient education:

  • Sick day rules: Double or triple the oral hydrocortisone dose during illness, fever, or stress (e.g., 20 mg TDS for 3 days). If vomiting, seek emergency care for IV hydrocortisone.
  • Emergency kit: Carry an injectable hydrocortisone (e.g., 100 mg IM) and a steroid card.
  • Medical alert bracelet.
  • Avoid dehydration and treat infections promptly.
  • Do not stop medications abruptly.

Pharmacology:

  • Hydrocortisone is identical to cortisol, a glucocorticoid with some mineralocorticoid activity. It has a short half-life (~90 minutes). It is used for replacement therapy and stress doses. At high doses (>50 mg/day), it provides significant mineralocorticoid effect.
  • Fludrocortisone is a synthetic mineralocorticoid with potent sodium-retaining and potassium-excreting effects. It has negligible glucocorticoid activity. It is used to replace aldosterone in Addison's disease. Monitor for hypertension, edema, and hypokalemia.

Note: In adrenal crisis, do not delay hydrocortisone for diagnostic tests. The patient should be educated on stress dosing and emergency administration.