Adrenal insufficiency Recogni2on & Management. Prof. Simon Pearce

Transcription

1 Adrenal insufficiency Recogni2on & Management Prof. Simon Pearce

2 Declara2on Received speaker fees from: Merck- Serono Shire

3 Objec2ves Recognise Addison s disease Understand and treat adrenal crisis Raise awareness of steroid dependency

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5 Not an isolated event 39 F Depression, gastroenteribs Fatal 24 F EaBng disorder Fatal 12 M Food Fads. Raised TSH hypothyroidism Fatal 34 M Weight loss, pigmentabon, gynaecomasba waibng list for Synacthen test Respiratory arrest Hypoxic brain damage

6 67% of pabents had 3 or more encounters with features of adrenal failure before Δ 50% of men, 70% of women had complained of symptoms > 6 months 68% had a different inibal diagnosis Mental health GastrointesBnal Bleicken B et al. Am J Med Sci 2010

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8 Presenta2on of adrenal crisis Hypotension, postural Tachycardia (bradycardia) Collapse, confusion VomiBng, diarrhoea Abdominal pain, back pain, muscle spasm

9 Biochemical features Hyponatraemia 90% Hyperkalaemia 50% Acidosis Hypoglycaemia Hypercalcaemia High TSH

10 Pathophysiology of adrenal crisis Salt deplebon: mineralocorbcoid effect Hypotension, postural Tachycardia (bradycardia) Electrolyte disturbance: back pain, muscle spasm GlucocorBcoid deficiency VomiBng, diarrhoea Loss of appebte, weight loss, hypoglycaemia

11 Causes of adrenal emergencies 4% 3% 2% 1% 8% of Addisonian pabents per year Vomiting Diarrhoea 6% Flu-like illness 6% Vomiting 37% Blackout/Unconscious Surgical recovery Major infection 7% Injury/Severe pain 10% Flu Diarrhoea Shock Other Don t know 24% UK survey results 2003 N = 432 White & Arlt Eur J Endo 2010

12 Non- acute diagnosis Weight loss is invariable, early sabety, nausea Some pabents adapt very well to salt loss Ask about salt cravings/ dietary habits Niggling abdominal pain, muscle cramps common

13 Management of Adrenal Crisis IM/IV HydrocorBsone 100mg Repeat 50mg IM/IV 6hrly or 100mg 8hrly Or 200mg/24hrs by IV infusion IV 0.9% saline 1000 mls stat ConBnue 1000 mls 2 hrly, 4hrly, 6 hrly, 8 hrly Look for precipitabng factors InfecBon Husebye ES et al. Consensus statement. J Intern Med 2013 Arlt W etal. SfE Emergency Guideline. Endocrine Conn 2016

14 Ongoing management Despite salt- deplebon fludrocorbsone isn t necessary in first instance Doses of HydrocorBsone >50mg daily act on mineralocorbcoid receptor Many pabents may be safely discharged once taking oral medicabon, olen 24 to 48hrs aler admission Review with the pabent the opportunibes to avert the crisis or admission? Frequent crisis pabent?

15 Chronic Management: glucocor2coid 2 or 3 doses of hydrocorbsone daily Small dose of prednisolone also acceptable 3 or 4 mg (3+1) Start early and avoid doses aler 17:00hrs Titrate and adjust dose Bming according to diurnal wellbeing

16 Napier & Pearce, Current Opinion EDO 2014

17 Little & often in HCT dosing >90% of corbsol is bound to corbsol- binding globulin (CBG) Excess (unbound) plasma corbsol is rapidly excreted in urine Howle&, Clin Endo 1997

18 Little & often in HCT dosing >90% of corbsol is bound to corbsol- binding globulin (CBG) Excess (unbound) plasma corbsol is rapidly excreted in urine Howle&, Clin Endo 1997

19 Chronic Management: mineralocor2coid FludrocorBsone mcg daily Younger people need more Discuss salt cravings, including typical foods Consider salt tablets (NaCl g/d) Titrate according to Na + /K +, BP, renin

20 Ae2ology

21 Ae2ology of adrenal failure Primary adrenal failure (Addison s disease) Lose all 3 adrenocorbcal hormones ACTH deficiency- pituitary disease (secondary) GlucocorBcoid deficiency MineralocorBcoid intact Exogenous suppression of ACTH (terbary) 5 mg or more of prednisolone daily

22 Establish Ae2ology Pazderska & Pearce, Clin Med 2017

23 Drug effects: Be alert Mechanism Exogenous suppression Central suppression Impaired steroidogenesis Increased clearance (CYP3A4 induc9on) Decreased clearance (CYP3A4 inhibi9on) Drugs Inhaled and topical steroids Opiates (tramadol) Ketoconazole, (fluconazole) Etomidate Rifampicin, phenytoin, topiramate Ritonavir, Itraconazole

24 Drug effects: Be alert Ritonavir (HAART), itraconazole stop steroid excrebon PaBent olen taking flubcasone, beclamethasone inhaler Appear Cushinoid due to excess steroid effects May have profound adrenal suppression despite trivial steroid use

25 Steroid dependency

26 } Prednisolone >5mg HydrocorBsone >20 mg Dexamethasone >1mg for 3 weeks Time for adrenal atrophy caused by lack of ACTH

27 Na2onal steroid card

28 Steroid dependency audit ( ) 50 MAU admissions 84% on prednisolone, median dose 8mg (1 to 40) DuraBon of therapy 8.3 yrs (<1 mo to 30yrs) No pabent had medic alert jewellery 28% had a steroid card 34% had no change in dose 55% of those taking 6mg prednisolone or less 2 pabents didn t receive any steroid medicabon unbl >24 hrs aler admission

29 Implemented an e- Record alert

30 Train junior doctors & make a protocol

31 Ambulance Service Registra2on (NEAS) Covers a populabon of ~ 2.6 million people Berwick > Guisborough > Haltwhistle There is a flag system in place for people with adrenal insufficiency Alerts call- handlers and ambulance crews that the pabent has adrenal insufficiency and may be having an adrenal crisis Must be GP or hospital doctor inibated

32 Pa2ent Educa2on Steroid card & Medical alert jewellery iphone medic alert home screens Sick day rules Fever, diarrhoea Minor procedures (denbst, gastroscopy) VomiBng How & when to inject with IM hydrocorbsone

33 Addison s disease SUMMARY PresentaBon Pathopysiology of adrenal crisis Acute and chronic management Steroid dependency Drug awareness PaBent educabon is key Missed steroid doses should be a never event Take home 3 QIPs

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35 Thank you Anna Mitchell Catherine Napier Richard Quinton Muhammad Asam Kerry Devine Vikram Lal Margaret Morris Katherine White & ADSHG

36 BMJ Oct 2012

37 Problems of adrenal insufficiency pa2ents Missed diagnosis Anorexia nervosa Depression Delayed emergency treatment Lack of knowledge in A&E (despite pabent asserbons) Denied access to necessary medicabon Nil by mouth in hospital not wrizen up GP 28- day prescribing