scholarly journals ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of adrenal insufficiency

2020 ◽  
Vol 183 (1) ◽  
pp. G25-G32 ◽  
Author(s):  
Wiebke Arlt ◽  
Stephanie E Baldeweg ◽  
Simon H S Pearce ◽  
Helen L Simpson
Keyword(s):  
Adrenal Insufficiency ◽  
Clinical Deterioration ◽  
Adrenal Crisis ◽  
Modified Release ◽  
Risk Of Infection ◽  
Course Of Disease ◽  
Restricted Access ◽  
Increased Risk ◽  
Sick Day Rules ◽  
Stress Dose

We provide guidance on prevention of adrenal crisis during the global COVID-19 crisis, a time with frequently restricted access to the usual level of healthcare. Patients with adrenal insufficiency are at an increased risk of infection, which may be complicated by developing an adrenal crisis; however, there is currently no evidence that adrenal insufficiency patients are more likely to develop a severe course of disease. We highlight the need for education (sick day rules, stringent social distancing rules), equipment (sufficient glucocorticoid supplies, steroid emergency self-injection kit) and empowerment (steroid emergency card, COVID-19 guidelines) to prevent adrenal crises. In patients with adrenal insufficiency developing an acute COVID-19 infection, which frequently presents with continuous high fever, we suggest oral stress dose cover with 20 mg hydrocortisone every 6 h. We also comment on suggested dosing for patients who usually take modified release hydrocortisone or prednisolone. In patients with adrenal insufficiency showing clinical deterioration during an acute COVID-19 infection, we advise immediate (self-)injection of 100 mg hydrocortisone intramuscularly, followed by continuous i.v. infusion of 200 mg hydrocortisone per 24 h, or until this can be established, and administration of 50 mg hydrocortisone every 6 h. We also advise on doses for infants and children.

scholarly journals The incidence of adrenal crisis in the postoperative period of HPA axis insufficiency after surgical treatment for Cushing’s syndrome

2019 ◽  
Vol 181 (2) ◽  
pp. 201-210 ◽  
Author(s):  
Leonie H A Broersen ◽  
Femke M van Haalen ◽  
Tina Kienitz ◽  
Olaf M Dekkers ◽  
Christian J Strasburger ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Cushing’S Syndrome ◽  
Cushing's Syndrome ◽  
Adrenal Crisis ◽  
Pituitary Hormone ◽  
Increased Risk ◽  
Potential Risk Factors ◽  
Life Threatening ◽  
Glucocorticoid Deficiency

Background Adrenal crisis, the most feared complication of adrenal insufficiency, is a potentially life-threatening state of acute glucocorticoid deficiency. After successful surgery for Cushing’s syndrome, many patients develop (transient) adrenal insufficiency. The incidence of adrenal crisis in patients treated for hypercortisolism is unknown. Methods Cohort study included consecutive patients with Cushing’s syndrome with adrenal insufficiency after surgery from Leiden and Berlin from 2000 to 2015. We summarized the incidence of adrenal crisis, compared patients with and without adrenal crisis regarding potential risk factors for its occurrence and assessed the effect of better education in time on incidence of adrenal crisis. Results We included 106 patients, of whom 19 patients had a total of 41 adrenal crises. There were 9.0 crises per 100 patient-years at risk (95% confidence interval (CI): 6.7–12.0). All crises occurred while on hydrocortisone replacement. The risk ratio for a recurrent crisis was 2.3 (95% CI: 1.2–4.6). No clear change in incidence of adrenal crisis due to better education in time was observed. There was no difference in recurrence rate between patients with, and without any crisis, but patients with adrenal crisis had more often pituitary deficiencies. Conclusions The incidence of adrenal crises after treatment for Cushing’s syndrome is substantial, and patients who suffered from an adrenal crisis have higher risk for recurrent crisis. Adrenal crisis tends to present early after remission of Cushing’s syndrome, which is probably the period of severest HPA axis suppression, despite in general higher hydrocortisone replacement doses for withdrawal complaints in this period. Additional pituitary hormone deficiencies may be a risk marker for increased risk of adrenal crisis. However, further risk factor analysis is needed to identify risks for a first crisis. Effective education methods to prevent adrenal crises should be identified and implemented, including stress instructions by trained nursing staff before hospital discharge.

scholarly journals Frequently Asked Questions in Patients With Adrenal Insufficiency in the Time of COVID-19

2021 ◽  
Vol 12 ◽  
Author(s):  
Chiara Sabbadin ◽  
Corrado Betterle ◽  
Carla Scaroni ◽  
Filippo Ceccato
Keyword(s):  
Adrenal Insufficiency ◽  
Short Review ◽  
Acute Illness ◽  
Self Management ◽  
Vaccine Hesitancy ◽  
Adrenal Crisis ◽  
Risk Of Infection ◽  
Telemedicine Consultation ◽  
Life Threatening ◽  
Cortisol Deficiency

Adrenal insufficiency (AI) is a life-threatening disorder, with increased morbidity and mortality, especially in case of an acute illness that can increase the requirement of cortisol. A novel infectious disease, termed Coronavirus Disease 2019 (COVID-19), appeared in 2020. Therefore, AI patients are experiencing a novel challenge: the risk of infection. In our experience, a prompt contact to the Endocrine center (with a telemedicine consultation) and a full awareness of diseases (cortisol deficiency, COVID-19 and the self-management of an adrenal crisis) are important to motivate patients. Vaccine is an effective treatment to prevent hospitalization and aggressive course of COVID-19. Some patients manifest challenges due to inequitable access and vaccine hesitancy, resulting in a delay in the acceptance of vaccines despite the availability of vaccination services. Therefore, an effort of all physicians must be conducted in order to advise patients with AI. In this short review, we try to answer some frequently asked questions regarding the management of patients with AI.

Perioperative Adrenal Crisis

2017 ◽  
Author(s):  
Jing Tao ◽  
Jeffrey J. Schwartz
Keyword(s):  
Adrenal Insufficiency ◽  
Adrenal Crisis ◽  
Life Saving ◽  
Distributive Shock ◽  
Threatening Condition ◽  
Life Threatening ◽  
High Doses ◽  
Patient At Risk ◽  
Stress Dose ◽  
Timely Treatment

Perioperative adrenal insufficiency (AI) (adrenal crisis) is an uncommon life-threatening condition manifested by distributive shock that is poorly responsive to the administration of fluids and vasopressors. Timely treatment with high doses of glucocorticoids can be life saving. The difficulty is in recognizing the patient at risk, suspecting the diagnosis, and distinguishing it from other forms of shock. The incidence of adrenal crisis is rare, in large part, due to the liberal use of perioperative “stress dose” steroids in patients already receiving steroids. In this chapter we review the pathophysiology involved in both primary and secondary AI, and provide step-by-step treatment recommendations for patients as risk for this condition.

Adrenal Insufficiency and Response to Stress Dose Hydrocortisone in Patients With Cirrhosis and Vasopressor Dependency Using Cirrhosis-Specific Cortisol Thresholds

2020 ◽  
Vol 54 (8) ◽  
pp. 742-749
Author(s):  
Trenton Vu ◽  
Meghna Vallabh ◽  
Greg Laine
Keyword(s):  
Adrenal Insufficiency ◽  
Standard Dose ◽  
Lower Mortality ◽  
Vasopressor Therapy ◽  
Baseline Cortisol ◽  
Increased Risk ◽  
Secondary Endpoints ◽  
Response To Stress ◽  
Stress Dose ◽  
Similar Incidence

Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL). Use of HC was at the discretion of the intensivist. The primary endpoint was days of vasopressor therapy. Secondary endpoints included hospital mortality and newly acquired infections. Sixty-four patients were evaluated; 40 patients received HC and 24 did not. Results: Mean random cortisol was significantly lower in the HC group (9.8 ± 3.2 vs 12.0 ± 3.7 µg/dL, P = 0.04). Delta cortisol also tended to be lower in the HC group (8.2 ± 4.4 vs 11.3 ± 6.4 µg/dL, P = 0.25). Patients in the HC group exhibited significantly fewer median days of vasopressor therapy (4.0 [2.0-7.0] vs 7.0 [4.2-10.8], P = 0.006), lower mortality (22.5% vs 50%, P = 0.02), and a similar incidence of newly acquired infections. Conclusion and Relevance: The use of HC in patients meeting cirrhosis-specific criteria for AI resulted in significantly shorter duration of vasopressor therapy, lower mortality, and no increased risk of infection. Use of traditional AI definitions may exclude patients with cirrhosis that could benefit from HC therapy.

scholarly journals Perioperative glucocorticoid management based on current evidence

2021 ◽  
Vol 16 (1) ◽  
pp. 8-15
Author(s):  
Kwon Hui Seo
Keyword(s):  
Adrenal Insufficiency ◽  
Surgical Stress ◽  
Perioperative Period ◽  
Hemodynamic Instability ◽  
Current Evidence ◽  
Major Surgery ◽  
Adrenal Crisis ◽  
Number Of Patients ◽  
Glucocorticoid Administration ◽  
Stress Dose

Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.

scholarly journals Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings

2019 ◽  
Vol 68 (1) ◽  
pp. 16-25 ◽  
Author(s):  
Bradley S Miller ◽  
Sandra P Spencer ◽  
Mitchell E Geffner ◽  
Evgenia Gourgari ◽  
Amit Lahoti ◽  
...  
Keyword(s):  
Emergency Management ◽  
Adrenal Insufficiency ◽  
Early Recognition ◽  
Action Plan ◽  
Sodium Succinate ◽  
Urgent Care ◽  
Adrenal Crisis ◽  
Care Providers ◽  
Endocrine Society ◽  
Stress Dose

Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient’s HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient’s home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.

scholarly journals Corticosteroids Replacement in a Patient With Panhypopituitarism and COVID-19 Infection

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A578-A579
Author(s):  
Gowri Karuppasamy ◽  
Zaina Abdelhalim Alamer ◽  
Samman Rose ◽  
Ibrahim Abdulla Al-Janahi
Keyword(s):  
Pituitary Adenoma ◽  
Adrenal Insufficiency ◽  
Hormone Replacement ◽  
Hypogonadotropic Hypogonadism ◽  
Adrenal Crisis ◽  
High Dose ◽  
Pituitary Hormone ◽  
Secondary Hypothyroidism ◽  
Stress Dose

Abstract Background: Hypopituitarism refers to complete or partial insufficiency of pituitary hormone secretion and patients require lifelong hormone replacement. Those with ACTH deficiency rely on exogenous glucocorticoids and at times of intercurrent illness require stress doses to prevent an adrenal crisis. The benefits and adverse effects of corticosteroids for treatment of COVID-19 pneumonia are currently under investigation. We report our experience in a patient with COVID-19 pneumonia who received high dose corticosteroids for panhypopituitarism. Clinical Case: A 51-year-old man presented with one-week history of fever and generalized weakness. He had been diagnosed with a non-functional pituitary macro-adenoma causing panhypopituitarism 1 year ago when he developed generalized tonic-clonic seizures. He underwent trans-sphenoidal resection of the pituitary adenoma. However, he then discontinued his hormonal therapy and was lost to follow up. He had postural hypotension but was not tachypneic or hypoxemic. He tested positive for COVID-19 and chest x-ray showed prominent bilateral broncho-vascular markings; he was hospitalized as mild COVID-19 pneumonia. Laboratory investigations revealed secondary adrenal insufficiency, secondary hypothyroidism and hypogonadotropic hypogonadism. MRI of the pituitary now showed persistence of the pituitary macroadenoma, measuring 3.5 x 3.7 x 2.4 cm in dimensions, causing sellar obliteration and left cavernous sinus invasion. Treatment with stress dose steroids, Hydrocortisone 50 mg 4 times daily was initiated, followed by thyroid hormone replacement with Levothyroxine 125 mcg daily. He also received antivirals and supportive care for COVID-19, guided by local hospital protocol. After significant clinical improvement, steroids were tapered down and he was discharged on a maintenance dose of 20 mg hydrocortisone per day in divided doses. The patient was stable at outpatient follow up after one month. He was started on testosterone replacement for erectile dysfunction due to hypogonadotropic hypogonadism. He was offered surgery for complete resection of the residual pituitary adenoma, but he declined and preferred to continue medical therapy. Conclusion: Hypopituitarism is associated with significant morbidity and premature mortality, a key risk factor being cortisol deficiency. Adrenal crisis is a life-threatening medical emergency and remains an important cause of death in patients with adrenal insufficiency. These patients are also vulnerable to develop severe complications from COVID-19 infection due to the absence of normal cortisol responses to stress. Despite receiving stress dose corticosteroids, this high-risk patient recovered from COVID-19 pneumonia without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in patients with COVID-19.

Hypopituitarism

2013 ◽  
Author(s):  
Liana G Hosu ◽  
Lori A Aronson
Keyword(s):  
Pituitary Gland ◽  
Adrenal Insufficiency ◽  
Corticosteroid Treatment ◽  
Pituitary Hormones ◽  
Adrenal Crisis ◽  
Dose Corticosteroid ◽  
Stress Dose

Hypopituitarism refers to decreased secretion of pituitary hormones, which can result from diseases of the pituitary gland or hypothalamus. Surgery in the presence of untreated panhypopituitarism is rare. It is important to recognize the presence of hypopituitarism and most importantly adrenal insufficiency, a condition that can result in mortality from adrenal crisis without stress-dose corticosteroid treatment.

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