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Table 4. Measures for Prevention of Adrenal Crisis
Action Point Intervention
Identify and define
the problem
Steroid emergency card (check that card is available and up to
date).
Medical alert bracelet or necklace: "Adrenal insufficiency –
needs steroids!"
Educate patient (and
partner/parents)
Sick day rule 1: need to double the routine oral glucocorticoid
dose when the patient experiences fever or illness requiring bed
rest, when requiring antibiotics for an infection, or before a
small outpatient procedure (eg, dental work).
Sick day rule 2: need to inject a glucocorticoid preparation
IM or IV in case of severe illness, trauma, persistent vomiting,
when fasting for a procedure (colonoscopy!), or during surgical
intervention.
100 mg hydrocortisone IV, IM, or subcut followed by 200 mg
hydrocortisone per continuous IV infusion, alternatively
repeated bolus doses (IV or IM) q6h.
Give special
attention to:
Explaining the rationale for dose adjustment in stress/sickness.
Discussing the situations requiring dose adjustment.
Discussing symptoms and signs of emergent adrenal crisis.
Teaching parenteral self-administration of glucocorticoid
preparation.
Enforcing the need to go to hospital aer emergency injection.
Provide patient
with:
Sufficient supply of hydrocortisone and fludrocortisone
(accounting for possible sick days).
Hydrocortisone emergency injection kit prescription (vials of
100 mg hydrocortisone sodium, syringes, needles; alternatively,
also hydrocortisone or prednisolone suppositories).
Leaflet with information on adrenal crisis and hospitalization to
be shown to health care staff.
Clearly advise regarding the need to inject 100 mg
hydrocortisone immediately IV or IM, followed by continuous
infusion of 200 mg/24 h.
Emergency phone number of endocrine specialist team.
Follow-up Reinforce education and confirm understanding during each
follow-up visit (at least annually in a patient without specific
problems or recent crises; otherwise, more frequently).
Adapted from I. Bancos, et al: Diagnosis and management of adrenal insufficiency. Lancet
Diabetes Endocrinol. 2015;3:216–226 (122), with permission. © Elsevier Limited.
