As endocrinologists, we are all aware of the importance of recognising adrenal insufficiency and treating it appropriately. We are familiar with the distinction between primary and secondary adrenal insufficiency and the variety of causes that can lead to the condition.¹

Perhaps less well-recognised amongst specialties outside endocrinology is the ability of prescribed, exogenous steroids to cause suppression of the hypothalamo-pituitary-adrenal axis, leading to so-called ‘tertiary adrenal insufficiency’. This can leave the patient vulnerable to the risk of adrenal crisis in exactly the same way as classical primary and secondary adrenal insufficiency.² This is made all the more relevant when we bear in mind the large number of patients who take regular, prescribed glucocorticoid treatment. Most of these patients have never seen an endocrinologist. Such treatments, across all routes of administration (oral, parenteral, inhaled, topical, intra-articular) have the potential to cause adrenal suppression, and this can often be overlooked.³ Whilst there is a lack of prospective evidence to document the risks of adrenal crisis in this group, there is an increased mortality associated with prescribed steroid use, even when correcting for the underlying medical condition.⁴

Adrenal crisis is a life-threatening endocrine emergency, and treatment relies upon the provision of emergency parenteral glucocorticoids, fluid resuscitation and treating any underlying cause.⁵ It can occur in primary, secondary and tertiary adrenal insufficiency and, therefore, rapid and appropriate treatment is fundamental. The National Reporting and Learning System identified 78 incidents, including 2 deaths and 6 incidents of severe harm to patients, in a recent 4-year period, all relating to the omission of steroids during severe intercurrent illness or around a surgical procedure.

Elective surgery is a well-recognised stress. In patients with adrenal insufficiency, it is crucial to ensure circulating glucocorticoid levels are adequate, in order to cope with the physiological stresses associated with the procedure.

A PLACE FOR NEW GUIDANCE

Prompted by a report from HM Coroner into standards of care for patients with adrenal insufficiency, the Association of Anaesthetists of Great Britain and Ireland, the Society for Endocrinology, the Royal College of Anaesthetists and the Royal College of Physicians have come together to produce the first national guidance on the topic that specifically integrates expertise in endocrinology with the practicalities of anaesthetic and surgical services delivery, and addresses the needs of both adults and children.⁶

These guidelines have now been published in the journal Anaesthesia, the official journal of the Association of Anaesthetists of Great Britain and Ireland, where it will have broad readership amongst practising anaesthetists.⁶

The key take-home messages include the following:

• prescribed glucocorticoid therapy can cause suppression of the hypothalamo-pituitary-adrenal axis
• all glucocorticoid-dependent patients are at risk of adrenal crisis as a consequence of surgical stress or illness
• patients should be involved in their own care, as they are often well informed; also, work closely with the local endocrine team
• the suggested specific parenteral glucocorticoid regimens depend upon the procedures being performed; these must be tailored in the postoperative period, depending upon recovery and complications
• dexamethasone is not a suitable replacement glucocorticoid as it lacks mineralocorticoid activity
• special considerations need to be made for children and obstetric patients.

Through the incorporation of this guidance into clinical practice, we hope that patients with adrenal insufficiency (from whatever cause) never suffer an adrenal crisis through lack of administration of parenteral glucocorticoid therapy at the time of surgery.

THE NEXT STEPS

Optimising and ensuring the highest quality of care for patients with adrenal insufficiency is paramount. In parallel with this new guidance, ongoing work is bringing together the Society for Endocrinology, the Royal College of Physicians Safety Committee and the British National Formulary, all co-ordinated through NHS England and NHS Improvement. The aim is to further heighten awareness of adrenal insufficiency and its consequences, and to deliver and distribute a new NHS steroid emergency card. This will replace the somewhat outdated blue steroid card that many patients still carry with them. The launch of the new steroid card is imminent: keep watching Society for Endocrinology communications for updates and details.

Jeremy Tomlinson, Professor of Metabolic Endocrinology, Medical Sciences Division, University of Oxford

Helen Simpson, Consultant Endocrinologist, Department of Diabetes and Endocrinology, UCLH NHS Foundation Trust, London

REFERENCES

1. Bancos I et al. 2015 Lancet Diabetes & Endocrinology 3 216–226.
2. Smans LC et al. 2016 Clinical Endocrinology 84 17–22.
3. Woods CP et al. 2015 European Journal of Endocrinology 173 633–642.
4. Souverein PC et al. 2004 Heart 90 859–865.
5. Arlt W et al. 2016 Endocrine Connections 5 G1–G3.
6. Woodcock T et al. 2020 Anaesthesia doi:10.1111/anae.14963 (In Press).

READ NEW GUIDELINES FOR MANAGING ADRENAL INSUFFICIENCY

The Society for Endocrinology, the Association of Anaesthetists and the Royal College of Physicians have published new ‘Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency’. You can access the guidelines from the Anaesthesia website: https://doi.org/10.1111/anae.14963.