A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes

Abstract

Background: Adrenal patients have a lifelong dependency on steroid replacement therapy and are vulnerable to sudden death from undertreated adrenal crisis. Urgent treatment with parenteral steroids is needed, often with IV saline for volume repletion. Episodes of adrenal crisis are, for most patients, relatively infrequent and they may not be well prepared to respond. This study explores how patients recall previous episodes of adrenal crisis and their satisfaction with UK emergency medical treatment. Methods: We invited members of the main UK support groups representing steroid-dependent adrenal patients to complete an online questionnaire identifying the number, causes and location of previous adrenal crises (episodes needing injected steroids and/or IV fluids). Respondents were asked to rate the adequacy of their medical treatment in 2 successive questionnaires, conducted 2013 and 2017-18. Results: Vomiting was the major factor identified as a cause of adrenal crisis, indicated by 80% of respondents. The most common location, at 70%, was the home. Of the 30% away from home, 1 in 3 were overseas or travelling long-distance. Self-treatment played an increasing role in emergency response: in the 5 year interval between questionnaires an increasing number of patients self-injected. By the time of the 2017-18 survey self-injection was the most common method of initial treatment, with less than two-thirds travelling to hospital for follow-up medical treatment. This finding help to explain the higher rate of adrenal crisis identified in patient surveys than in hospital records. Satisfaction with medical care received stayed constant between the 2 surveys despite growing resourcing pressures across the NHS. Two-thirds were happy with the quality of the medical treatment they received for their most recent adrenal emergency; timeliness was the main factor influencing satisfaction. Conclusions: Around one-third of adrenal patients report sub-optimal treatment at emergency medical departments. Medical staff have a low probability of encountering adrenal crisis and may be unfamiliar with either the urgency of adrenal crisis or the specific treatment response it requires. Comprehensive protocols for emergency medical staff with detailed patient education and training are needed in how to respond to this infrequently encounteredbut acutely life-threateningscenario.

Therapeutic Patient Education for Adrenal Insufficiency under COVID-19 Pandemic Conditions

“…One reason for this shortcoming might be insufficient knowledge of physicians of AI. Only less than 10 % of interviewed physicians identified all situations requiring glucocorticoid adjustment correctly [38,39]. Another reason might be the low recognition value of different emergency cards handed out to patients.…”

“…Recent data from a prospective study showed that patients who performed a self-injection had an improved outcome: after initial parenteral (intramuscular or subcutaneous) glucocorticoid administration by patients or their relatives, significantly more patients were treated on an outpatient basis (62%) compared to patients who did not self-inject (27%), (p=0.008) 37 . Two surveys from 2013 and 2017/18 in British patients revealed that within a 5-year interval more patients performed self-injection for treatment of emergency situations (16.7% versus 24%) 40 .…”

Metabolic and Endocrine Challenges

“…The epidemiology is nonnegligible with 5 to 17 AC cases occurring per 100 patient-years in patients with primary or SAI. 132 The mortality rate is high, estimated between 0.5 and 2%. 133,134 Precipitating Factors Several factors can be involved in precipitating an AC, commonly including interruption of glucocorticoid intake, infections, surgery, gastroenteritis, and emotional or physical stress.…”

The insidious threat of jamu and unregulated traditional medicines in the COVID-19 era

“…This issue is compounded by the closure of shops, stalls, and businesses and the implementation of a lockdown by the government. In steroid-dependent individuals, sudden cessation of these unregulated drugs may lead to adrenal insufficiency and eventually adrenal crisis, a life-threatening condition [6,7].…”