James K. Rone, MD, FACP, FACE

"Rescue Kits" for an Adrenal Crisis

September 10, 2016

Tags: Adrenal Insufficiency

I have been corresponding with the daughter of an elderly physician who passed away at least partly as a result of inadequate management of an "adrenal crisis" in which an illness or injury or surgery can't be tolerated by a patient missing adequate adrenal function, if they don't receive emergency doses of glucocorticoid steroids. In the wake of recent new stories about EpiPens, she asked me about home injection kits for adrenal patients, paralleling products available to severely allergic patients and those with diabetes, who might suffer a low blood sugar. Here was my reply to that interesting question…

I haven't specifically looked but I have never heard of a specific "rescue kit" manufactured for adrenal insufficiency patients, analogous to the EpiPen for anaphylactic shock and GlucaGen for diabetes. Obviously injectable and suppository hydrocortisone products do exist and could be prescribed to patients to have on hand for emergency use, although it is not to my knowledge and common or even recommended practice. I don't believe I have ever done so. And, no, I have no specific manufacturers to recommend.

I have two answers to why this is so. The first might not be very satisfying: adrenal insufficiency is not as common as diabetes or severe allergies to penicillin, bee stings, and peanuts. The second answer is that the "rescue kit" for AI is patient education plus the usual oral glucocorticoid replacement agents, typically hydrocortisone or prednisone. By that I mean, patients should be instructed by their physicians to double their usual doses on certain kinds of sick days (high fever, for instance). When the illness or developing adrenal crisis is so severe as to cause nausea and vomiting, preventing oral intake of glucocorticoids, then the patient must either contact his or her physician urgently, or go to the ER. That of course presupposes that the resource--the ER for example--believes the patient and knows what to do. The wearing of a Medic-Alert bracelet identifying the patient unequivocally as an adrenal insufficiency suffer IS a common recommendation and should cut through any questions in an ER.

Proper treatment then in the ER would be to treat the underlying illness causing the crisis, making sure hydration is maintained with IV fluids if needed, and providing adequate (often "stress dose") glucocorticoid replacement by IV or rectally, until oral dosing can reliably resume. That of course may involve a hospital admission.

So, why should not parenteral (that is, rectal or by intramuscular shot) glucocorticoids be available to patients at home? Simple. A single big dose of hydrocortisone, for instance, would provide short-term support, but once it's cleared from the body in 8 or 12 hours, the patient will be right back in trouble again, and perhaps worse. If for example the crisis were brought on by a severe infection, like pneumonia, the situation might well be worse in 8-12 hours if the infection hasn't gotten treatment. It might be worse due to the normal progression of the infection if unchecked by antibiotics, or the hydrocortisone shot might have made things worse. Steroid replacement might well be life-saving for some of the patient's problems, but since it suppresses the immune system, the pneumonia might easily worsen, the patient become septic possibly, and die for that reason.

In other words, it is much more likely that a single patient-administered dose of epinephrine or glucagon will definitively see a patient through an entire episode of a food allergy or "insulin shock," than a single steroid shot would see an AI patient through a crisis.

I hope that helps.

Dr. Rone

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