Adrenal insufficiency Flashcards
What are the symptoms of adrenal insufficiency? (7)
- Fatigue
- GI upset
- Anorexia
- Weight loss
- Musculoskeletal symptoms
- Salt cravings
- Dizziness or syncope due to hypotension
What are the life-threatening symptoms of adrenal crisis? (7)
- Severe dehydration
- Hypotension
- Hypovolaemic shock
- Altered consciousness
- Seizures
- Stroke
- Cardiac arrest
Which drugs (when stopped) most commonly causes adrenal insufficiency
Glucocorticoids
If glucocorticoids are stopped or decreased too quickly after prolonged use, endogenous glucocorticoid production may not be sufficient to meet the body’s needs
What card should all patients with adrenal insufficiency and steroid dependence carry with them?
Steroid Emergency Card
What are the treatment aims for adrenal insufficiency?
- Reduce symptoms
- Reduce the risk of complications (e.g. adrenal crisis)
- Improve overall quality of life
Which 3 drug options can be used in adrenal insufficiency for glucocorticoid replacement?
- Hydrocortisone (most similar to cortisol)
- Prednisolone
- Dexamethasone (rarely used)
Which glucocorticoid replacement therapy is most similar to cortisol?
Hydrocortisone
Modified release (oral): 20-30 mg once daily (in the morning)
Immediate-release (oral): 20-30 mg daily in divided doses
Which drug is used in primary adrenal insufficiency for mineralocorticoid replacement?
Fludrocortisone acetate
- Oral: 50-300 micrograms once daily
For aldosterone deficiency
Patients with primary adrenal insufficiency need both (?) replacement AND (?) replacement
Glucocorticoid replacement (hydrocortisone)
Mineralocorticoid replacement (fludrocortisone acetate)
When a patient with adrenal insufficiency is undergoing “stress”, which medication do they need to increase to prevent an adrenal crisis?
Glucocorticoid replacement (hydrocortisone)
Stress = surgical or invasive procedures, intercurrent illness
For a patient with adrenal insufficiency and moderate intercurrent illness (fever or infection requiring antibacterial), by how much should their daily glucocorticoid replacement be increased?
Doubled
Patients with adrenal insufficiency on long-acting hydrocortisone preparations should switch to short-acting, more rapidly absorbed preparations during an intercurrent illness
For a patient with adrenal insufficiency and severe intercurrent illness (e.g. persistent vomiting from GI viral illness), what change should they make to their glucocorticoid replacement?
IM or IV hydrocortisone should be given
Patients with adrenal insufficiency are at higher risk of glucocorticoid deficiency if they are vomiting or have diarrhoea.
What type of illness result in a higher risk of glucocorticoid deficiency in patients with adrenal insufficiency?
Vomiting and diarrhoea
If you suspect a patients is having an adrenal crisis, should you wait for investigations before giving them a bolis of hydrocortisone?
NO
There is no adverse consequence of initiating a life-saving bolus dose of hydrocortisone treatment.
What is the treatment of an adrenal crisis?
Prompt glucocorticoid replacement with hydrocortisone
AND
Rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%)
Why do you not need to give increased mineralocorticoid replacement (fludrocortisone) to a patient with an adrenal crisis?
High-dose hydrocortisone has sufficient mineralocorticoid effect to cover this
During an adrenal crisis, particular care is required in patients with which disease?
Diabetes insipidus
They are at risk of uncontrolled diabetes insipidus if doses of desmopressin are omitted or hyponatraemia if excess fluid is given.
Following an adrenal crisis and prior to hospital discharge, all patients should be referred to an endocrinologist for… (2)
- Advice on ongoing treatment
2. Education around ‘sick day rules’
Fludrocortisone has very high (glucocorticoid/mineralocorticoid?) activity and insignificant (glucocorticoid/mineralocorticoid?) activity
Fludrocortisone has very high MINERALOCORTICOID activity and insignificant GLUCOCORTICOID activity
Hydrocortisone has (equal/unequal?) glucocorticoid and mineralocorticoid activity
equal
Can hydrocortisone muco0-adhesive buccal tablets be used to treat adrenal insufficiency?
NO
Only indicated for local use in the mouth for aphthous ulceration
In elderly patients talking corticosteroids, when would you consider the prescription to be potentially inappropriate (STOPP criteria)? (4)
- If used instead of inhaled corticosteroids for maintenance therapy in moderate to severe COPD (unnecessary exposure to long-term side-effects)
- As long-term (> 3 months) monotherapy for rheumatoid arthritis
- For treatment of osteoarthritis other than for periodic intra-articular injections for monoarticular pain
- With concurrent NSAIDs without proton pump inhibitor prophylaxis
For patients receiving systemic corticosteroids (or those who have used them within the previous 3 months) who have NOT had the chickenpox, what should they receive?
Passive immunisation with varicella-zoster immunoglobulin
What is the concern if a patient taking systemic corticosteroids gets the chickenpox
Risk of severe (fulminant) chickenpox
Manifestations of fulminant illness - pneumonia, hepatitis, DIC
If a patient taking systemic corticosteroids gets chickenpox should you stop treatment with corticosteroids?
NO
Dosage may need to be increased
If a patient taking systemic corticosteroids is exposed to measles, what prophylactic treatment may be needed?
IM normal immunoglobulin
What are the psychiatric side effects associated with systemic corticosteroids?
- Euphoria
- Insomnia
- Irritability
- Mood lability
- Suicidal thoughts
- Psychotic reactions
- Behavioural disturbances
Can psychiatric reactions occur during withdrawal of corticosteroid treatment?
Yes, rarely
They most commonly occur with high-doses of corticosteroids
What needs to be monitored if children are taking prolonged corticosteroids?
Height and weight (annually)
For a disease that is unlikely to relapse, what are the other reasons should you consider a gradual withdrawal of systemic corticosteroids? (6)
- Received more than 40 mg prednisolone (or equivalent) daly for more than 1 week
- Been given repeat doses in the evening
- Received more than 3 weeks’ treatment
- Recently received repeated courses (particularly if taken for longer than 3 weeks)
- Taken a short course within 1 year of stopping long-term therapy
- Other possible causes of adrenal suppression
When can you consider stopping systemic corticosteroids abruptly in adults?
Disease is unlikely to relapse
AND
Have received treatment for 3 weeks or less
AND
Not included in the patient groups below:
- Received more than 40 mg prednisolone (or equivalent) daly for more than 1 week
- Been given repeat doses in the evening
- Received more than 3 weeks’ treatment
- Recently received repeated courses (particularly if taken for longer than 3 weeks)
- Taken a short course within 1 year of stopping long-term therapy
- Other possible causes of adrenal suppression
During corticosteroid withdrawal the dose may be reduced rapidly down to psychological doses. What is the equivalent of psychological doses in prednisolone?
7.5 mg daily prednisolone
Then reduce more slowly
Who should be given a Steroid Emergency Card? (5)
- Primary adrenal insufficiency
- Adrenal insufficiency due to hypopituitarism requiring corticosteroid replacement
- Taking corticosteroids at doses equivalent to, or exceeding, prednisolone 5 mg daily for 4 weeks or longer acress all routes of administration
- Taking corticosteroids at doses equivalent to, or exceeding, prednisolone 40 mg daily for longer than 1 week, or repeated short oral courses
- Taking a course of oral corticosteroids within 1 year of stopping long-term therapy
