Adrenal crisis after first infusion of zoledronic acid: a case report

Patients with Addison's disease are at greater risk of having reduced bone mineral density and hip fractures and are thus more likely to receive a bisphosphonate than their peers. Potent intravenous bisphosphonates could provoke an acute phase reaction. An 80-year-old female with Addison's disease received her first infusion of zoledronic acid for osteoporosis at our outpatient clinic around noon. Despite doubling her usual afternoon hydrocortisone dose, she became feverish, nauseous, extremely weak, and hypotensive over the night. When transported to the nearest general hospital the next morning, the patient was found to have signs of hypovolemic shock and she was admitted to the ICU. Crystalloid infusion, followed by dobutamine and norepinephrine drip, had no effect. Only after her European emergency card for glucocorticoid cover was found, adrenal crisis was recognized, and she was immediately given an intravenous bolus of hydrocortisone followed by continuous hydrocortisone infusion. The patient rapidly improved and was transferred to a regular ward the next day, where hydrocortisone dose was gradually tapered. Our experience might suggest that patients with Addison's disease should probably start their treatment with zoledronic acid in a hospital setting. Their usual oral dose of hydrocortisone should be doubled or even tripled. Careful monitoring of these patients seems to be warranted, and intravenous hydrocortisone should be given if any symptoms or signs of the imminent adrenal crisis are noted.