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Patient education and safety measures for adults with chronic adrenal insufficiency

Patient education and safety measures for adults with chronic adrenal insufficiency
  1. Patient education
Educate patient about the disease, how to manage minor illnesses and major stressors, and how to inject hydrocortisone or other glucocorticoid intramuscularly or subcutaneously.
Refer to UpToDate patient education topics on adrenal insufficiency (Addison disease).
  1. Emergency precautions
Obtain medical alert bracelet/necklace, Emergency Medical Information Card, and injectable glucocorticoid (eg, hydrocortisone 100 mg).
  1. Treatment of minor febrile illness or surgical stress
Increase glucocorticoid dose 2- to 3-fold for the few days of illness. Do not change mineralocorticoid dose.
Patient is instructed to contact clinician if illness worsens or persists for more than 3 days.
No extra supplementation is needed for most uncomplicated, outpatient dental procedures under local anesthesia.
Glucocorticoid dosing for surgical stress:
  • Minor (eg, herniorrhaphy) – An extra dose of hydrocortisone 25 mg IV (or equivalent) on day of procedure
  • Moderate (eg, orthopedic surgery) – Hydrocortisone 50 to 75 mg IV (or equivalent) on day of surgery and postoperative day 1
  • Major (eg, cardiac bypass) – Hydrocortisone 100 mg IV prior to the procedure and 150 to 200 mg IV (or equivalent) in 3 or 4 divided doses on day of surgery and postoperative days 1 and 2

Then return to usual daily glucocorticoid dose if postoperative course is uncomplicated.
General anesthesia or IV sedation should not be performed in the office setting.
  1. Emergency treatment of severe stress or trauma
Each patient should have an injectable glucocorticoid (eg, 100 mg vials of hydrocortisone), needles and syringes for injection, and vials of sterile 0.9% normal saline (if needed for reconstitution).
Instruct patient/caregivers on how to reconstitute the vial and to inject entire dose intramuscularly or subcutaneously in event of severe stress or trauma. Patient should seek medical help immediately after injection.
IV: intravenously.

Courtesy of Lynette Nieman, MD.

Additional data from:
  1. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016; 101:364.
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