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Adrenal emergency steroid card. Permission to reprint granted by the Addisons Disease SelfHelp Group, addisonsdisease.org.uk

Adrenal emergency steroid card. Permission to reprint granted by the Addisons Disease SelfHelp Group, addisonsdisease.org.uk

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Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and sym...

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... recommend that all patients should carry steroid emergency cards. 18,51 An emergency steroid wallet card that is credit-card sized is available (Figure 1). It contains advice on the emergency treatment of an adrenal crisis and has been authored by expert endocrinologists in the field of adrenal disease and endorsed by the European Society of Endocrinology, the International Society of Endocrinology and a number of patient support groups. ...

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Background Coronavirus disease 2019 is an emerging respiratory disease caused by a novel coronavirus effect on 10-20% of total healthcare workers and was first detected in December 2019 in Wuhan, China. This study was designed to assess effect of COVID-19 stressors on healthcare workers’ performance and attitude. A descriptive cross sectional resea...

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... Previous studies reported an increased risk of infections and increased hospitalization and mortality rates in AI patients compared to controls [76][77][78]. An additional concern is a high risk of an adrenal crisis during severe infections [79]. Even when AI patients receive optimal treatment, the morbidity and mortality rates continue to be higher than in the general population ...
... Previous studies reported an increased risk of infections and increased hospitalization and mortality rates in AI patients compared to controls [76][77][78]. An additional concern is a high risk of an adrenal crisis during severe infections [79]. Even when AI patients receive optimal treatment, the morbidity and mortality rates continue to be higher than in the general population [73]. ...
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Coronavirus disease 2019 (COVID-19) is a highly heterogeneous disease regarding severity, vulnerability to infection due to comorbidities, and treatment approaches. The hypothalamic–pituitary–adrenal (HPA) axis has been identified as one of the most critical endocrine targets of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that might significantly impact outcomes after infection. Herein we review the rationale for glucocorticoid use in the setting of COVID-19 and emphasize the need to have a low index of suspicion for glucocorticoid-induced adrenal insufficiency, adjusting for the glucocorticoid formulation used, dose, treatment duration, and underlying health problems. We also address several additional mechanisms that may cause HPA axis dysfunction, including critical illness-related corticosteroid insufficiency, the direct cytopathic impacts of SARS-CoV-2 infection on the adrenals, pituitary, and hypothalamus, immune-mediated inflammations, small vessel vasculitis, microthrombotic events, the resistance of cortisol receptors, and impaired post-receptor signaling, as well as the dissociation of ACTH and cortisol regulation. We also discuss the increased risk of infection and more severe illness in COVID-19 patients with pre-existing disorders of the HPA axis, from insufficiency to excess. These insights into the complex regulation of the HPA axis reveal how well the body performs in its adaptive survival mechanism during a severe infection, such as SARS-CoV-2, and how many parameters might disbalance the outcomes of this adaptation.
... Ein wichtiges Ziel bei der Behandlung der NNI ist die Prävention und Therapie der Nebennierenkrise (auch akute NNI oder Addison-Krise genannt) [4][5][6][7][8][9]. Patient*innen mit einer primären NNI ha-ben ein höheres Risiko für eine Nebennierenkrise als Patient*innen mit sekundärer oder tertiärer NNI, und das Risiko ist besonders dann erhöht, wenn man erst vor kurzer Zeit eine Nebennierenkrise hatte. ...
... Die Amerikanische Gesellschaft für Endokrinologie ("Endocrine Society") definiert die Nebennierenkrise als einen medizinischen Notfall mit erniedrigtem Blutdruck (Hypotension), ausgeprägten abdominellen Beschwerden und deutlichen Laborveränderungen,dereine unmittelbare Therapie erfordert [3]. Die Definition der Nebennierenkrise ist somit unscharf und international bisher auch nicht einheitlich [3][4][5][6][7][8][9]. Eine häufig verwendete pragmatische Definition der Nebennierenkrise ist eine akute Beeinträchtigung des Gesundheitszustands in Verbindung mit absoluter Hypotension (systolischer Blutdruck < 100 mmHg) oder relativer Hypotonie (systolischer Blutdruck ≥ 20 mmHg niedriger als üblich), mit Veränderungen, die sich innerhalb von 1 bis 2 h nach Verabreichung von Glukokortikoiden deutlich verbessern (z. ...
... B. Infekten ist auch deswegen erhöht, da sich dabei eine Glukokortikoidresistenz (Cortisolresistenz) ausbilden kann mit möglicher Entwicklung eines Teufelskreislaufs, bei dem durch Zytokinwirkungen die Glukokortikoidresistenz immer größer wird und durch die zu geringe Glukokortikoidwirkung die Zytokinfreisetzung nicht mehr ausreichend supprimiert werden kann [5]. Die folgenden Dosierungsempfehlungen basieren auf empirischen Expertenmeinungen und beziehen sich auf Maßnahmen, die von den Patient*innen selbst oder ihren Angehörigen nach entsprechender Schulung durchgeführt werden sollen [1][2][3][4][5][6][7][8]. ...
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Zusammenfassung Um in der Therapie der kortikotropen Insuffizienz das physiologische Cortisolprofil besser nachahmen zu können, wurden in den letzten Jahren zwei Hydrocortisonpräparate mit verzögerter Wirkstofffreisetzung entwickelt. Plenadren®, ein Hydrocortisonpräparat mit zweistufiger Wirkstofffreisetzung für den Morbus Addison, kann den frühmorgendlichen Cortisolanstieg nicht imitieren, aber möglicherweise Lebensqualität und einige metabolische Parameter verbessern. Chronocort (Efmody®), ein Hydrocortisonpräparat mit veränderter Wirkstofffreisetzung mit abendlicher und morgendlicher Einnahme („toothbrush regimen“), kann ein nahezu physiologisches Cortisolprofil nachahmen und ist in der Therapie des adrenogenitalen Syndroms zugelassen, noch nicht aber für den Morbus Addison.
... Ein wichtiges Ziel bei der Behandlung der NNI ist die Prävention und Therapie der Nebennierenkrise (auch akute NNI oder Addison-Krise genannt) [4][5][6][7][8][9]. Patient*innen mit einer primären NNI ha-ben ein höheres Risiko für eine Nebennierenkrise als Patient*innen mit sekundärer oder tertiärer NNI, und das Risiko ist besonders dann erhöht, wenn man erst vor kurzer Zeit eine Nebennierenkrise hatte. ...
... Die Amerikanische Gesellschaft für Endokrinologie ("Endocrine Society") definiert die Nebennierenkrise als einen medizinischen Notfall mit erniedrigtem Blutdruck (Hypotension), ausgeprägten abdominellen Beschwerden und deutlichen Laborveränderungen,dereine unmittelbare Therapie erfordert [3]. Die Definition der Nebennierenkrise ist somit unscharf und international bisher auch nicht einheitlich [3][4][5][6][7][8][9]. Eine häufig verwendete pragmatische Definition der Nebennierenkrise ist eine akute Beeinträchtigung des Gesundheitszustands in Verbindung mit absoluter Hypotension (systolischer Blutdruck < 100 mmHg) oder relativer Hypotonie (systolischer Blutdruck ≥ 20 mmHg niedriger als üblich), mit Veränderungen, die sich innerhalb von 1 bis 2 h nach Verabreichung von Glukokortikoiden deutlich verbessern (z. ...
... B. Infekten ist auch deswegen erhöht, da sich dabei eine Glukokortikoidresistenz (Cortisolresistenz) ausbilden kann mit möglicher Entwicklung eines Teufelskreislaufs, bei dem durch Zytokinwirkungen die Glukokortikoidresistenz immer größer wird und durch die zu geringe Glukokortikoidwirkung die Zytokinfreisetzung nicht mehr ausreichend supprimiert werden kann [5]. Die folgenden Dosierungsempfehlungen basieren auf empirischen Expertenmeinungen und beziehen sich auf Maßnahmen, die von den Patient*innen selbst oder ihren Angehörigen nach entsprechender Schulung durchgeführt werden sollen [1][2][3][4][5][6][7][8]. ...
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Zusammenfassung Ein wichtiges Ziel bei der Behandlung der Nebenniereninsuffizienz ist die Prävention der Nebennierenkrise (auch akute Nebenniereninsuffizienz oder Addison-Krise genannt). Um in Österreich eine bessere Implementierung sowie Harmonisierung der Maßnahmen zur Prävention und Therapie der Nebennierenkrise zu erreichen, wurde dieses Konsensusdokument erarbeitet. Folgende Maßnahmen werden grundsätzlich für alle Patient*innen mit Nebenniereninsuffizienz empfohlen und in diesem Manuskript ausführlich erörtert: 1. Versorgung mit einer Notfallkarte („steroid emergency card“) sowie evtl. auch mit einem Armband oder einer Halskette (oder Ähnlichem) mit medizinischem Alarmhinweis „Nebenniereninsuffizienz, benötigt Glukokortikoide“. 2. Versorgung mit einem Hydrocortison-Notfallkit zur Injektion (alternativ auch Suppositorien/Zäpfchen zur Notfallapplikation) sowie ausreichenden oralen Glukokortikoiddosen für Stresssituationen/Erkrankungen. 3. Schulung von Patient*innen und Angehörigen zur Steigerung der Glukokortikoidtherapie in Stresssituationen bzw. bei Erkrankungen („sick day rules“) und zur Selbstinjektion von Hydrocortison. 4. Versorgung mit einer Behandlungsleitlinie (Informationszettel) zur Prävention und Therapie der Nebennierenkrise, welche bei Bedarf auch dem Gesundheitspersonal gezeigt werden soll. 5. Versorgung mit einer Notfall-Telefonnummer des behandelnden endokrinologischen Teams und/oder medizinisch geschulter Betreuungspersonen bzw. Angehöriger. 6. Regelmäßige (vorzugsweise jährliche) Wiederholung der Schulungsmaßnahmen. Dieses Konsensusdokument beinhaltet auch ausführliche Empfehlungen für die perioperative Glukokortikoidtherapie sowie für diverse andere Stresssituationen.
... Previously, physicians struggled with proper adjustment of glucocorticoid doses in the hospital, consequently increasing hospital LOS. 21 More recently, physicians may have more knowledge of glucocorticoid adjustments in emergent and inpatient situations. Patient education also has an important effect on LOS, as seen in a study that showed that patients with higher adherence to their glucocorticoid treatments had a reduced inpatient LOS. ...
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Adrenal insufficiency (AI) is a severe disease that is difficult to manage in both inpatient and outpatient settings. This study describes trends, inpatient outcomes, and the disease burden of hospitalizations for patients with AI. Data are included on hospitalizations with a principal discharge diagnosis of AI using ICD codes from the National Inpatient Sample for the years 2008, 2010, 2012, 2014, 2016, and 2018. Patients <18 years and those with elective hospitalizations were excluded. From 2008 to 2018, the number of AI hospitalizations increased significantly (P-trend < 0.001), with a rising trend in the proportion of patients with Charlson Comorbidity Index scores >3. There was a significant downward trend in the length of stay from 2008 to 2018 (P-trend = 0.005). However, there was no statistically significant trend for mortality or mean total hospital charges during hospitalizations (P-trend = 0.050 and 0.076, respectively). In conclusion, AI hospitalizations significantly increased over the 10 years with an overall decrease in length of stay.
... Governed by the hypothalamic-pituitary-adrenal (HPA) axis, cortisol is synthesized and released in a circadian pattern to promote daytime arousal and respond to stress and other cues (Ramamoorthy and Cidlowski, 2016). The upregulation of cortisol forms part of a cyclical response that triggers hepatic gluconeogenesis and reduces insulin sensitivity (Adam et al., 2010), inhibits inflammatory immune response (Adam et al., 2017), and adjusts electrolyte homeostasis via the mitigation of hyperkalemia and hyponatremia (Dineen et al., 2019). In electrolyte rebalancing, the presence of glucocorticoids stimulates the renal endothelial sodium channel alpha subunits and upregulates sodium channels, facilitating a sodium-potassium ion exchange (Sayegh et al., 1999;Taves et al., 2011). ...
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11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) activity is implicated as a moderator of the progression of multiple diseases and disorders in medicine and is actively subject to investigation as a therapeutic target. Here we summarise the mechanisms of the enzyme and detail the novel agents under investigation. Such agents modulate peripheral cortisol and cortisone levels in hypertension, type 2 diabetes, metabolic disorders, and Alzheimer's disease models, but there is mixed evidence for transduction into symptom management. There is inchoate evidence that 11β-HSD1 modulators may be useful pharmacotherapies for clinical improvement in psychiatry and neurology; however, more research is required.
... Adrenal crisis is characterized as an acute deterioration in health status associated with hypotension, and concomitant features include acute abdominal pain, delirium, obtundation, hyponatremia, hyperkalemia, hypoglycemia, and pyrexia [5]. It may occur due to inflammation secondary to an infection, nonadherence to glucocorticoid replacement therapy, or secondary to serious acute conditions in which endogenous cortisol production is insufficient, including a surgical procedure or trauma [5,6]. ...
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Bezoars are aggregates of undigested materials that accumulate in the gastrointestinal lumen. They are a rare cause of small bowel obstruction and are mostly diagnosed in patients with small bowel disease. Patients with panhypopituitarism are more susceptible to developing metabolic and haemodynamic instability, particularly during perioperative period. We present the case of a male patient with small bowel obstruction secondary to a bezoar. The patient was admitted to the hospital due to upper abdominal pain and emesis, presenting with clinical signs of shock. He had a history of iatrogenic panhypopituitarism and had been submitted to a bilateral inguinal hernioplasty 15 days before. Abdominopelvic computed tomography with angiography revealed small bowel obstruction secondary to a bezoar. Stress-dose hydrocortisone was administered to treat the underlying haemodynamic instability, followed by exploratory laparotomy. The bezoar was removed and eventually the patient recovered with a tapering regimen of hydrocortisone. The diagnosis of small bowel obstruction secondary to bezoar can be challenging. The shock could be related to an adrenal crisis precipitated by the bezoar in the setting of increased susceptibility due to the recent surgery.
... Undetected adrenal insufficiency may be life-threatening. Therefore, testing adrenal function in HD patients, especially after glucocorticoid therapy or in chronic hypotensive patients is a common procedure [10,11]. The adrenocorticotropic hormone (ACTH) test is a standard test for diagnosing AI. ...
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Background Secondary adrenal insufficiency is a frequent issue in patients with renal replacement therapy. There are concerns about metabolism and clearance for adrenocorticotropic hormone (ACTH) and cortisol in addition to hemoconcentration as confounding factors during hemodialysis (HD). Therefore, ACTH testing is currently performed before or in between HD sessions. This review of the literature aims to evaluate the current evidence for validity of testing for adrenal insufficiency in patients on chronic renal replacement therapy. Methods A literature search of PubMed database for interventional and observational clinical trials was performed. Case reports and reviews were excluded. The search included all articles published until July 2020. Results Of 218 potentially eligible articles, 16 studies involving 381 participants were included. Seven studies performed an ACTH test before HD or in between HD sessions. There was no data available regarding ACTH testing during HD. But there was evidence of decreased cortisol levels during HD as compared to afterwards. All included 16 studies measured basal cortisol, and seven studies performed an ACTH test. Seven trials had comparable data of baseline cortisol for a quantitative analysis. Standardized mean difference of overall cortisol was 0.18 nmol/l (95%CI − 0.08 to 0.44) in the case group. Conclusions In patients undergoing renal replacement therapy, basal serum cortisol values are comparable to healthy volunteers. There is limited data on the validity of stimulated cortisol in these patients, especially during HD. Trial registration Registration no. CRD42020199245 .
... Adrenal crisis is associated with several risk factors such as chronic adrenal insufficiency, infection, trauma, or surgery [10,14,15]. It might appear as the first manifestation of adrenal insufficiency in around 8 per 100 patients with adrenal insufficiency per year, but it is often diagnosed late due to its nonspecific symptoms [16]. Other clinical symptoms that may appear are fever, dehydration, nausea and vomiting, anorexia, weakness, hypoglycemia, and loss of consciousness [1]. ...
... Corticotropin stimulation test, also known as cosyntropin test or ACTH test, is considered the gold standard for the diagnosis of primary adrenal insufficiency [17] and should be performed to confirm diagnosis in patients with clinical signs and symptoms of primary adrenal insufficiency, unless the results of basal cortisol levels are indicative of adrenal insufficiency [18]. Accordingly, it is recommended that therapy is started in patients with severe symptoms of adrenal insufficiency or adrenal crisis, without waiting for the result of a confirmatory test [2,12,16]. Presently, there is no laboratory marker available to confirm adrenal crisis, and diagnosis is based on the clinical presentation of the patient [9]. ...
Article
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Primary adrenal insufficiency, also known as Addison’s disease, is a rare but potentially fatal condition resulting from the failure of the adrenal cortex to produce glucocorticoid and/or mineralocorticoid hormones. Unfortunately, the clinical manifestation of primary adrenal insufficiency is not specific and often progresses insidiously, resulting in late diagnosis, or in severe cases, life-threatening circulatory collapse. Adrenal insufficiency should be considered in patients with unexplained vascular collapse. We report the case of a woman who presented to the emergency ward with unexplainable shock that was later diagnosed as adrenal crisis due to Addison’s disease. The presence of hyperpigmentation in patients with rapid progression of adrenal insufficiency suggests the diagnosis of Addison’s disease presenting with adrenal crisis.
... In patients with primary AI, the addition of fludrocortisone is necessary to correct the concurrent mineralocorticoid deficiency. Fludrocortisone should be introduced once the hydrocortisone dose is less than 50 mg/day since, at higher doses, hydrocortisone exerts adequate mineralocorticoid effects [145]. ...
Introduction Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS). Areas covered In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV. It also focuses on the pathophysiology, aetiology, diagnosis and management of this endocrinopathy in PLHIV. A literature review was conducted through Medline and Google Scholar search on the subject. Expert opinion Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with non-specific signs and symptoms and may be potentially life threatening if left untreated. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. Overt primary AI also necessitates mineralocorticoid replacement. On the other hand, the management of relative AI remains controversial. In order to reduce the risk of adrenal crisis during periods of stress, the short-term use of glucocorticoids may be necessary in relative AI.
... is was supported by the result that ambulatory early morning cortisol was the only independent predictor for HPA axis recovery after prolonged glucocorticoid use [29]. On the other hand, it was reported that the patients with adrenal insufficiency, especially adrenal crisis, often have clinical features such as hypotension, hyponatremia, and hypoglycemia [8,23,30,31]. As the etiology and severity of CAI are various [16,32], we supposed that this negative result about clinical features might be because the subjects admitted to this study were postoperative CD patients who accepted routine HPA axis function evaluation. ...
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Background: The suppressed hypothalamic-pituitary-adrenal (HPA) axis after successful surgery for Cushing's disease (CD) will recover in almost all patients. We aimed to identify the predictive factors for HPA axis recovery in CD patients with postoperative remission. Design and Methods. This observational retrospective cross-sectional study enrolled 69 CD patients with postoperative remission in Huashan Hospital from 2015 to 2019. All subjects had a detailed clinical evaluation. The low-dose ACTH stimulation test (LDT) was conducted as the gold standard for assessing the HPA axis function. Results: Peak cortisol in LDT was found only to be positively correlative with morning serum cortisol (MSC) (ρ=0.451, p < 0.001). The MSC was higher (p < 0.001), and the median postoperative course was significantly longer (p=0.025) in the patients with the recovered HPA axis function compared with unrecovered patients. The AUC value of MSC for predicting the recovery of the HPA axis was 0.701, and the optimal cutoff was 6.25 μg/dl (sensitivity 85.19% and specificity 47.62%). Other useful cutoff values were 10.74 μg/dl (specificity 100%) and 4.18 μg/dl (sensitivity 100%). Besides, combined with the postoperative course, the AUC values were higher than MSC alone (0.935 vs. 0.701, p < 0.001). Conclusions: MSC is a viable first-step diagnostic predictor for HPA axis recovery in CD patients with postoperative remission. For the patients with cortisol levels between 4.18 and 10.74 μg/dl, a confirmatory test should be conducted. When the MSC level was 10.74 μg/dl or greater, the replacement therapy could be discontinued.