Guidance for the prevention and emergency management of adult patients with adrenal insufficiency

Abstract

Adrenal insufficiency (AI) is an often-unrecognised endocrine disorder, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an intercurrent illness or surgery, can also lead to an adrenal crisis. The National Reporting and Learning System (NRLS) identified 78 incidents including two deaths and six incidents of severe harm to patients in a recent 4-year period. This guidance will go through causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. A new NHS Steroid Emergency Card has been developed to be carried by patients at risk of adrenal crisis. We hope the new emergency card and this guidance will increase awareness of the need to start steroids promptly in patients at risk of an adrenal crisis, particularly those presenting in the emergency department or to acute medicine teams and those undergoing surgery or invasive procedures.

Clinical pathways for patients with giant cell arteritis during the COVID-19 pandemic: an international perspective

“… Does the patient have COVID-19? Possible treatment approach New giant cell arteritis Giant cell arteritis Yes No Treat with high-dose glucocorticoid therapy to prevent vision loss; close follow-up to identify adverse effects; take measures to minimise risk of patient acquiring SARS-CoV-2 during health-care contacts COVID-19 misdiagnosed as giant cell arteritis Giant cell arteritis No Yes Avoid inappropriate glucocorticoid therapy; monitor for clinical deterioration; take measures to minimise risk of transmission of SARS-CoV-2 to other patients or staff New giant cell arteritis and concomitant COVID-19 Giant cell arteritis Yes Yes Treat with high-dose glucocorticoid therapy to prevent vision loss; close follow-up to identify adverse effects; take measures to minimise risk of transmission of SARS-CoV-2 to other patients or staff New giant cell arteritis misdiagnosed as COVID-19 COVID-19 Yes No Treat with high-dose glucocorticoid therapy to prevent vision loss; close follow-up to identify adverse effects; take measures to minimise risk of patient acquiring SARS-CoV-2 during health-care contacts Giant cell arteritis relapse Giant cell arteritis relapse Yes No Escalate giant cell arteritis therapy, including adjuvant immunosuppressant, if appropriate; take measures to minimise risk of patient acquiring SARS-CoV-2 during health-care contacts COVID-19 in a patient with prior diagnosis of giant cell arteritis Giant cell arteritis relapse No Yes Standard care for COVID-19; if already taking long-term, low-dose glucocorticoids for giant cell arteritis, consider short-term increase in dose to avert potential adrenal crisis, in line with recommendations for adrenal insufficiency 11 Giant cell arteritis relapse with concomitant COVID-19 Giant cell arteritis relapse Yes Yes Standard care for COVID-19; escalate giant cell arteritis therapy including adjuvant immunosuppressant if appropriate; take measures to minimise risk of transmission of SARS-CoV-2 to other patie...…”

“…These patients are thus at risk of adrenal crisis in the event of acute stressors, including sepsis. 11 Current endocrinology consensus recommends that, given the potential for rapid deterioration of patients with the severe systemic upset of COVID-19, patients at risk of adrenal insufficiency who develop COVID-19 might require extra stress doses of glucocorticoid to avert potential adrenal crisis. 33 …”

Endocrine toxicity of cancer immunotherapy: clinical challenges

“…Other patients can be commenced directly on replacement doses of corticosteroids (e.g. hydrocortisone 20 mg daily in divided doses or prednisolone 3 mg once daily ( 27 )). Indeed there are now reports of the safety of managing such patients on an out-patient basis ( 28 ).…”

Venoarterial extracorporeal membrane oxygenation as bridge to effective treatment in a 19-year-old woman with acute adrenal crisis: a case report

“…The primary adrenal insufficiency (PAI) is caused by a malfunction of the adrenal gland itself, often triggered by an autoimmune-mediated adrenalitis. 1 , 2 Secondary adrenal insufficiency is the result of an impaired hypothalamic–pituitary–adrenal axis and a consecutive disruption of adrenocorticotropic hormone (ACTH) synthesis. Patients suffering from PAI are at higher risk of an adrenal crisis compared to patients with secondary adrenal insufficiency due to differences in the severity of glucocorticoid deficiency.…”