Adrenal Crisis during COVID-19 pandemic

Our Clinical Committee have issued an advice statement with a summary to help keep adrenal insufficiency patients safe during the COVID-19 (Coronavirus) crisis.

 
Patients who suffer from a suspected or confirmed infection with coronavirus usually have high fever for many hours of the day, which results in the need for larger than usual steroid doses, so we advise slightly different sick day rules, which are listed below.

In patients with a suspected (or confirmed) coronavirus infection, we recommend:

Patients on hydrocortisone

• Please increase hydrocortisone to 20 mg four times daily every 6 hours
• Patients who usually take Plenadren should switch to the regular, immediate release hydrocortisone preparation and take 20 mg orally every 6 hours

Patients on prednisolone

• Patients on 5-15 mg prednisolone daily should take 10 mg prednisolone every 12 hours; patients on oral prednisolone >15 mg should continue their usual dose but take it split into two equal doses of at least 10 mg every 12 hours.

If on fludrocortisone, continue taking your usual daily dose.

General advice:

• Seek medical advice by calling 111 or accessing the coronavirus online information: https://111.nhs.uk/covid-19/
• Drink plenty of fluid and make sure you are passing urine regularly. You may need to wake in the night to keep drinking whilst fevers are high. If your urine is very dark, try to drink more fluids
• Take paracetamol 1000 mg every six hours

If they are short of breath, breathing fast, unable to talk in sentences or breathing is getting worse call 111 or 999 and take 100 mg IM emergency hydrocortisone injection.

Ensure patients have sufficient supplies to cover increased doses if they become unwell and an emergency injection of hydrocortisone 100 mg.

Coronavirus infections can come with 1-2 weeks of almost continuous fever. However, you need to watch if the infections gets worse – signs indicating a deterioration are dizziness, intense thirst despite drinking, shaking uncontrollably, drowsiness, confusion, and increasing shortness of breath (struggling to speak, struggling to breathe), which indicates that the coronavirus starts to attack the lung or other organs.

Advice:

• In this situation and also if any vomiting or severe diarrhoea develops you (or your carer/partner) should immediately self-inject 100 mg hydrocortisone intramuscularly using your emergency injection.
• You (or your partner/carer) should immediately call 999 to arrange for further treatment and transfer to the hospital.
• You should continue to take hydrocortisone at a dose of 50 mg every six hours until you are in hospital and can be started on intravenous hydrocortisone 200 mg per 24 hours.

If admitted to hospital very unwell we recommend:
1. Hydrocortisone 100 mg per IV injection followed by continuous IV infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or IM bolus injection)
2. Pause fludrocortisone
3. Intravenous Fluids

NHS Steroid Emergency Card

The SfE, RCP and NHSE/NHSI have been writing guidance to be released with a new NHS Steroid Emergency Card. To keep patients with adrenal insufficiency safe at this time, NHSE&I have agreed it is appropriate to release the card as a PDF that patients can download themselves.

This card and its associated guidance is intended for use by adults (16+). Infants up to 1 year may be given 25mg hydrocortisone intravenously; children 1 to 5 years, 50mg; 6 to 12 years, 100mg (1ml). This dose can be repeated three or four times in 24 hours depending upon the condition being treated and the patient's response.

If you need further information please email the British Society for Paediatric Endocrinology and Diabetes (BSPED) who are discussing separate guidance for children and adolescents. 

Adrenal insufficiency and molnupiravir

We are hearing some patients with adrenal insufficiency are being contacted and told they are eligible for molnupiravir. The only endocrine indication listed is autoimmune polyglandular pyndromes i.e. APS1/APECED and some of the rare genetic defects (eg. IPEX, STAT3) where patients are know to have a primary immunodeficiency. Steroid use and other forms of adrenal insufficiency are not mentioned in the NHS information.

Also note that Paxlovid (nirmatrelvir) contains ritonavir which for some people on exogenous steroids has a very significant steroid potentiating effect. Current treatment courses are for 5 days. Patients may need to be warned about this as it could worsen blood glucose control for people with diabetes.

Please consult these documents for further information:

• Notice to Stand Up Services for Targeted Deployment of COVID Treatments
• Letter to patients about new COVID-19 treatments

Coronavirus vulnerable adult advice

On the basis of current data, there is no evidence that patients with adrenal insufficiency are at increased risk of contracting coronavirus (COVID-19). However, we know that patients with Addison’s disease (primary adrenal insufficiency) and congenital adrenal hyperplasia have a slightly increased overall risk of catching infections. However patients who take steroids for endocrine conditions are at increased risk of becoming more unwell from coronavirus, and possibly having an adrenal crisis.

The government has issues a list of people considered vulnerable and this includes anyone instructed to get a flu jab as an adult each year on medical grounds as well as all people whose medication includes steroid tablets. Whilst adrenal insufficiency is not specifically mentioned in this guidance, both of these criteria apply to patients with adrenal insufficiency.

The government has issued guidance that our patients with these conditions should be to be particularly stringent in following social distancing measures and advise people to work from home, where possible.

Full measures are: 

• Avoid contact with someone who is displaying symptoms of coronavirus. These symptoms include high temperature and/or new and continuous cough
• Avoid non-essential use of public transport when possible
• Work from home, where possible. Your employer should support you to do this. Please refer to employer guidance for more information
• Avoid large and small gatherings in public spaces, noting that pubs, restaurants, leisure centres and similar venues are currently shut as infections spread easily in closed spaces where people gather together.
• Avoid gatherings with friends and family. Keep in touch using remote technology such as phone, internet, and social media
• Use telephone or online services to contact your GP or other essential services

Please read here for more detailed information.

Please note this is NOT the same advice as for the shielded category of patients