People with Addison’s (or other forms of steroid-dependence) who increase their oral medication according to the 'sick day rules' usually manage their illnesses smoothly, without going into adrenal crisis. But in cases of vomiting or shock,they can experience a sudden drop in blood pressure.
Anyone who is steroid-dependent needs to take extra steroid medication whenever they are sick or injured and before any kind of surgery. The general guidelines for extra steroid cover are:
- Double the normal dose of hydrocortisone for a fever of more than 37.5º C or for infection/sepsis requiring antibiotics.
- For severe nausea (often with headache), take 20mg hydrocortisone and sip rehydration/electrolyte fluids.
- On vomiting, use the emergency injection (100mg hydrocortisone) immediately. Then call a doctor, saying 'steroid-dependent patient', 'adrenal crisis' or 'Addison’s emergency'.
- Take 20mg hydrocortisone orally immediately for serious injury to avoid shock.
- Ensure your anaesthetist and surgical team, dentist or endoscopist are aware of your need for extra medication and that they have checked the ADSHG surgical guidelines for the correct level of steroid cover.
- It is advisable to take the ADSHG’s hospital pack (containing drugs chart stickers and other medical information) with you each time you go to hospital, for either emergency or elective treatment.
If you do not take sufficient extra steroid medication early enough in the course of an infection or injury, you may experience an adrenal crisis. Adrenal crisis is a state of acute cortisol shortage with similar symptoms to the pre-diagnosis illness. Warning signs include:
- severe nausea
- extreme weakness
- chills or fever
If you feel severely unwell, take extra steroid medication then call a doctor, saying steroid-dependent patient, adrenal crisis or Addison’s emergency.
An emergency injection of 100mg hydrocortisone, followed by immediate medical attention, is needed for an adrenal crisis. Depending on the severity of your symptoms, once the injection has been given, it's advisable to call 999 or call your GP. Depending on the severity of the infection, some individuals may deteriorate rapidly even after early self-injection with 100mg hydrocortisone IM. Hospital treatment may be required for 24 - 72 hours. Postural dizziness is a key indicator that IV fluids are necessary, usually requiring hospital admission.
Potentially life-threatening circulatory complications ranging from hypotension to hypovolaemic shock may occur if there are any delays in treating adrenal crisis. In extreme cases, if treatment is not obtained, this can lead to death.
Ambulance crews and GPs are advised that the acutely unwell patient should be stabilised by a saline infusion (for volume repletion) and a 100mg hydrocortisone injection before transportation to hospital. Any patient experiencing adrenal crisis should ideallly be transported flat and head first, especially when going down stairs. However, this may not be practical in some buildings and, if a carry chair is needed, the patient should be stabilised first as indicated above before being moved.
GPs are encouraged to ensure that steroid-dependent patients are given high priority for after hours or home visits when unwell, and that the ADSHG emergency treatment and surgical guidelines have been scanned into the patient’s notes.
- Clinical Knowledge Summaries, Addison’s disease.
- Husebye ES et al. 2014 Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency, J Intern Med. 275:104-15.
- Napier C & Pearce SH. 2014 Current and emerging therapies for Addison’s disease. Curr Opin Endocrinol Diabetes Obes. 21:147-53.
- Bancos I et al. 2015 Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol, 3:216-26.
- Arlt W. 2015 Adrenal Insufficiency: patient information sheet. Society for Endocrinology