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Clinical GuidelineMANAGEMENT OF PATIENTS TAKING STEROID MEDICATION (GLUCOCORTICOIDS) DURING ILLNESS, SURGERY, LABOUR OR OTHER INTER-CURRENT STRESSClinical GuidelineMANAGEMENT OF PATIENTS TAKING STEROID MEDICATION (GLUCOCORTICOIDS) DURING ILLNESS, SURGERY, LABOUR OR OTHER INTER-CURRENT STRESSSETTINGTrust wide (adults only)FOR STAFFAll Medical Staff and Non-Medical PrescribersFOR PATIENTSThis guidance is relevant to:Group A: Adult endocrine patients with proven glucocorticoid (cortisol) insufficiency due to either adrenal or pituitary/hypothalamic pathology and who are taking daily replacement glucocorticoid medicationGroup B: adult non-endocrine patients who are taking supra-physiological glucocorticoid therapy for inflammatory conditions (e.g. chronic obstructive airways disease, rheumatoid arthritis or inflammatory bowel disease) or haematological/oncological diseases at doses/durations that may suppress their own hypothalamic-pituitary-adrenal (HPA) axis.BackgroundGroup A patientsAdrenal insufficiency may occur as a primary (direct damage to the adrenal cortex) or secondary (damage to the upstream hypothalamic or pituitary pathways resulting in insufficient ACTH to stimulate the adrenal glands) endocrine condition. Primary adrenal insufficiency (often termed Addison’s disease) occurs when the adrenal cortex is destroyed by autoimmune disease, infection, septicaemia, haemorrhage, metastases or following adrenal surgery. Primary adrenal insufficiency is associated with both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiency and these patients will be taking daily replacement therapy with a glucocorticoid (hydrocortisone, prednisolone or dexamethasone) and a mineralocorticoid (fludrocortisone). Secondary adrenal insufficiency is associated with just glucocorticoid (cortisol) deficiency and these patients will be taking daily replacement therapy with a glucocorticoid (hydrocortisone, prednisolone or dexamethasone) medication.The most common glucocorticoid replacement regimen for endocrine patients with adrenal insufficiency is with hydrocortisone at doses of 10mg on waking, 5mg at midday and 5mg at around 5pm. Such a regimen offers the best chance of mimicking the natural circadian rhythm and restoring the best quality of life. However, many different individualised regimens (e.g. shift workers, patients taking medication that affects steroid metabolism) are used and as a guide the approximate steroid equivalent doses are shown below:Hydrocortisone 20mg = Prednisolone 5mg = Dexamethasone 0.75mg = Methylprednisolone 4mg = Cortisone acetate 25mgPlease also be aware that slow release glucocorticoid preparations are increasingly becoming available.Group B patientsPatients with no known endocrine disease may also be vulnerable to adrenal insufficiency as a consequence of being prescribed steroid (glucocorticoid) medication for an inflammatory condition such as chronic obstructive airways disease, rheumatoid arthritis or inflammatory bowel disease. The HPA axis becomes suppressed in response to glucocorticoid therapy of >5mg prednisolone per day (or equivalent) for any duration or any oral dose received for more than 3 weeks. Patients who have recently completed a long course (>3 weeks) of oral steroids should also be considered at risk of HPA axis suppression. Less commonly, chronic steroid use via inhaled, topical or other non-oral routes can suppress the HPA axis – these cases will need to be considered on an individual patient basis. In the context of inter-current illness, stress or surgery etc then there is no place for routine assessment of the HPA axis – simply assume insufficiency in this group of patients and manage accordingly.Cortisol plays a critical role in the body’s response to stress. It increases vascular tone thereby sustaining blood pressure, it mobilises energy to vital organs and it activates the immune system. In a deficient state, patients are at risk of adrenal crisis where they will become hypotensive, weak and lethargic. This may progress to confusion, coma and may even be fatal if untreated. In people with an intact HPA axis, cortisol levels rise rapidly and greatly when a stressor is encountered. In the patient groups described above – this natural response cannot occur due to HPA axis deficiency or suppression. It is critical, therefore, that glucocorticoid medication is increased promptly in these patients (no increase in fludrocortisone is required as the additional glucocorticoid will address any mineralocorticoid deficiency). Any increase should be proportionate to the stressor (see below). ‘Sick Day Rules’ advice - to be shared with the patient, patient’s family and GPGroup A patientsThe general advice for any serious illness is as follows:Double the normal daily glucocorticoid dose (no increase in Fludrocortisone is required) when the patient has a temperature of more than 37.50C (99.50F).The patient should be advised to contact their GP if their illness worsens or it lasts for more than 3 days and they should be advised to always seek medical help if their temperature reaches 400C (1040F). In severe illness, urgent medical assistance should be promptly sought (999 ambulance if appropriate).As soon as the patient’s temperature returns to normal, their steroid dose should be gradually tapered back to their normal daily dose within two days.If the patient experiences vomiting/diarrhoea then they should be advised to take an additional 20mg Hydrocortisone (or 5mg Prednisolone or 0.75mg Dexamethasone or 25mg Cortisone Acetate as relevant) immediately afterwards and they should sip rehydration/electrolyte fluids as long as they can tolerate these. If they experience repeated vomiting or diarrhoea then they should self-administer 100mg hydrocortisone intra-muscularly and seek urgent medical help.Typically the dose of steroids will only need to be increased for a couple of days if they have an illness that is transient and managed in the community. In the context of severe shock (e.g. a road traffic accident or bereavement) or a long haul flight (>12 hours), an increase in steroid medication is often appropriate. Steroid medication typically does not require increasing for viral colds without fever or general stress such as exams etc.If they are unable to take/absorb an increased dose of steroids orally because of vomiting or diarrhoea, they will urgently require steroid injections and should attend an Accident & Emergency Department or be seen by a Medical Practitioner at home quickly. Patients who experience a significant head injury or are involved in an accident that results in injury (e.g. fracture) should have a steroid injection and should attend an Accident & Emergency Department.Steroid Emergency PackAll patients should have 100mg Hydrocortisone for injection with needle and syringe [Hydrocortisone sodium phosphate (ready mixed liquid) or Solu-Cortef (powder plus vial of water)] available at home for use in an emergency. This should be administered promptly by any patient or carer or health care professional who is called out to visit the patient at home rather than being delayed until they reach hospital. The GP practice nurse may also be willing to teach the patient how to self-administer this injection should they wish to learn. Endocrine patients will have received appropriate advice and training from the endocrine nurse specialists. It is crucial to emphasise that should a patient be unwell enough to require an injection of hydrocortisone in the community then they should also promptly attend their local hospital as an emergency for assessment. Endocrine patients will routinely be asked if they are happy for their diagnosis of adrenal insufficiency and steroid dependence to be logged with the South West Ambulance service to facilitate safe pre-hospital care.Group B patientsThis group of patients should be advised about their risk of adrenal suppression and their potential increased vulnerability in the context of illness and to have a low threshold for seeking medical help. They should be advised that their steroid medication should never be abruptly stopped.Hospital admission with inter-current illnessAll patients who fit into groups A or B above will require an increase in their normal glucocorticoid medication if they are admitted to hospital with an inter-current illness; their steroid medication should never be stopped or omitted and should be switched to parenteral if the oral route is not viable (e.g. nil by mouth, vomiting, diarrhoea etc).If the patient is in an adrenal crisis then this represents a medical emergency and appropriate intravenous sodium chloride (0.9%), parenteral hydrocortisone (100mg iv 6 hourly) and treatment of the underlying cause should be promptly instituted.If there is no evidence of adrenal crisis, then for endocrine patients (group A), a doubling of normal oral medication as per sick day rules will frequently be sufficient for many. For non-endocrine patients (group B) a similar increase may be appropriate but for patients already on large baseline doses (e.g. patients receiving high dose prednisolone or dexamethasone as part of their chemotherapy regimen) an increase of less than 100% or even no increase may be judged clinically more appropriate. It would be unusual to require a dosage of >40mg Prednisolone or equivalent per day unless severely unwell. If illness severity is severe (e.g. MI, pancreatitis, significant trauma, severe sepsis) then consider parenteral (iv/im) hydrocortisone at doses of 50-100mg every 6-8 hours. In settings such as ICU, a continuous iv infusion of 150-300mg / 24 hours can be convenient. With recovery, the hydrocortisone should be gradually weaned back to the normal maintenance dose.Endocrine patients with a diagnosis of adrenal insufficiency and steroid dependence will have a specific alert recorded on the Trust Medway patient system to help highlight their risk to all healthcare professionals involved in their care.Pregnancy and LabourGroup A patientsAll patients with endocrine (primary or secondary adrenal insufficiency) disease should be referred and managed through the joint endocrine antenatal service based at St Michael’s Hospital. In endocrine patients, hydrocortisone is the replacement steroid of choice during pregnancy. Pregnancy is associated with a gradual, but significant physiologic increase in corticosteroid binding globulin and total serum cortisol. Free cortisol levels rise during the third trimester, typically resulting in an increased requirement for hydrocortisone of between 2.5 and 10 mg daily. There is no routine approach and this should be individualised by the endocrine team based on symptoms and baseline dosage. No biochemical monitoring of steroid replacement is required.The fludrocortisone dose (adrenal patients only) may also need to be increased during late pregnancy. Clinical evaluation of salt cravings, blood pressure and serum electrolytes is the best means for dosage monitoring and adjustment. With the onset of labour, a single parenteral (im or iv) dose of 100 mg of hydrocortisone should be given. No further increase in mineralocorticoid (fludrocortisone) replacement is required. 100mg dosage of parenteral hydrocortisone should be continued every 6 hours until delivery. The normal oral regimen should then be doubled for 24 – 48 hours postpartum (low threshold for further parenteral doses as for major surgery below if prolonged active phase of labour) and rapidly tapered back to normal thereafter. Any significant instrumental delivery, surgery or general anaesthetic should result in intramuscular or intravenous steroid injections instead of their normal oral replacement. Please see below under the surgical guidance notes. Post-partum, remember to advise that the patient may need to modify their normal glucocorticoid regimen based on their sleep pattern to ensure adequate energy levels. Typically the approach would be to alter the frequency of doses rather than to alter the total dosage for any prolonged period. Group B patientsThe potential increased vulnerability of this group of patients should be recognised and appropriate monitoring instituted. Their steroid medication should never be abruptly stopped and a temporary increase in their steroid dosage may be considered to cover labour and delivery, as for group B patients admitted to hospital with intercurrent illness (above).Surgery / interventional proceduresAny surgery requiring a general anaesthetic will require parenteral steroid cover for patients in both Groups A and B. The UHBristol endocrine physicians offer shared care for all their endocrine (group A) surgical in-patients. They will typically know the patients with adrenal and pituitary pathology and may be able to help in those with exogenous steroid HPA axis suppression. They also often provide a plan if elective surgery is planned via clinic letters. Minor procedures (e.g. dental extraction)Group A: Double normal oral dose for 24 hoursGroup B: Double normal oral dose for 24 hours or smaller proportional increase if clinically more appropriate Invasive intestinal procedures requiring laxatives (e.g. colonoscopy)Pre-procedure: Group A: Double normal oral dose for 24 hoursGroup B: Double normal oral dose for 24 hours or smaller proportional increase if clinically more appropriate Consider admission night before procedure with 100mg im/iv hydrocortisone and 0.9% saline ivProcedure: Group A and B: 100mg hydrocortisone im/iv immediately prior to procedurePost-procedure: Group A: Double normal oral dose for 24 hoursGroup B: Double normal oral dose for 24 hours or smaller proportional increase if clinically more appropriate Minor surgery /procedure (e.g. angiogram, hernia repair, cataract surgery)Group A and B: 100mg hydrocortisone im/iv immediately prior to procedurePost procedure:Group A: Double normal oral dose for 24 hoursGroup B: Double normal oral dose for 24 hours or smaller proportional increase if clinically more appropriate Major surgery with rapid recovery time (e.g. joint replacement, caesarean section)Group A and B: 100mg hydrocortisone im/iv immediately prior to procedurePost procedure:Group A and B: 50mg hydrocortisone im/iv every 6-8 hours. If procedure uncomplicated, then wean hydrocortisone by ~50% after 24 hours (25mg every 6-8 hours). Gradually wean back to normal maintenance steroid dosages over the next 1-2 days. Switch to oral hydrocortisone whenever it is a reliable route during the weaning process.Major surgery with prolonged recovery time (e.g. abdominal / cardiac surgery)Group A and B: 100mg hydrocortisone im/iv immediately prior to procedurePost procedure:Group A and B: 50mg hydrocortisone im/iv every 6-8 hours or a continuous iv infusion of 200mg hydrocortisone over 24 hours. If procedure uncomplicated, then wean hydrocortisone by ~30% per day back to normal maintenance dosage. Switch to oral hydrocortisone whenever it is a reliable route during the weaning process.Typically for major surgery 100-150mg hydrocortisone is appropriate over the first 24hours but this can be quickly reduced with recovery. This can be given in three or four divided iv or im boluses or as an iv infusion at a rate of 4mg/hr. For example:100 mg of intravenous or intramuscular Hydrocortisone with induction of general anaesthetic followed by 24 hours of Hydrocortisone 50mg three times daily via the intravenous/intramuscular route, decreasing to Hydrocortisone 20mg orally three times daily for 24 hours on second post-operative day and then reduce to double normal standard replacement (20mg on waking, 10mg at 12pm and 10mg at 5pm). Advise as prompt as possible a return to standard replacement Hydrocortisone (typically 10mg on waking, 5mg at 12pm and 5mg at 5pm).-------------------------------------------------------------------------------------------------------------------------------For patients with a diagnosis of primary adrenal failure (Addison’s disease) then additional information is available from the Addison’s Disease Self Help Group (.uk) and for patients with pituitary disease advice is available from The Pituitary Foundation (). All patients should be advised to wear a Medic Alert talisman "" medicalert.co.ukat all times to include the phrase ‘steroid dependant’. Medic Alert? can also be contacted during office hours, Mon-Fri, 9am-5pm on Free phone: 0800 581420.All patients should be advised to carry a ‘Steroid Card’. These are available from the BRI pharmacy.QUERIESEndocrine nurse specialists: bleep 6936, telephone extension 24017Endocrine advice bleep: 6216 (9am-5pm weekdays)USER GROUPS CONSULTED: Endocrinology, Surgery, Anaesthetics, Pharmacy, ED, Care of the Elderly, Rheumatology, Respiratory medicine, Obstetrics, Oncology, Haematology & Non-Medical Prescribers ................
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