Steroid replacement advice Information for patients Endocrinology
Cortisol is a hormone that is essential for life and wellbeing. It is produced in the adrenal glands. Steroid replacement therapy is needed because you have under-production of cortisol from your glands. Deficiency of steroids can occur if your adrenal or pituitary gland is not working, or if you have previously been on steroids. Important contacts Endocrinologist Endocrine nurse Telephone number: 0114 271 3714 Every day treatment Your drug is hydrocortisone or prednisolone or dexamethasone and your recommended daily regime is: On waking take 12 midday take Tea time (4-6pm) take Sick day treatment Normally when people are ill they produce more cortisol to help them get over the stress of their illness. You cannot do this so follow these simple rules: If you have: heavy colds with a fever infections needing treatment with antibiotics Double your daily dose for 3 days, if not improving continue for up to 7 days. If you are vomiting or don't improve on the above treatment, you need injections of steroids to be given immediately. page 2 of 8
Emergency treatment If you have diarrhoea and/or vomiting for more than a few hours your tablets will not be absorbed into your blood stream. As a result, you could become ill very quickly and experience some or all of these symptoms: dizziness weakness muscle cramps low blood pressure thirst diarrhoea vomiting These symptoms mean your steroid levels are very low and it could be life threatening if not treated immediately with an injection of Hydrocortisone. You must do one of these: give yourself the injection get a family member to give the injection get a GP to give the injection attend your nearest Accident and Emergency department with your steroid pack and tell them you need urgent medical care. If in doubt always give yourself the injection then seek medical attention via your GP or A&E. Follow the instructions with your hydrocortisone injection on drawing up and giving your injection. General tips Carry extra tablets with you, put spare tablets in your car, bag, jacket. Carry tablets on you, not in your suitcase Wear a medic alert identification Carry your steroid card and this leaflet with you Take injection on holiday with you. Check expiry date. Show medical personnel this leaflet if you are ill. You can get a prescription for your Hydrocortisone injections from your endocrine clinic, nurse or GP Non-endocrine patients should contact their specialist nurse as a first priority page 3 of 8
Adrenal Deficiency of Cortisol How to give an emergency injection of hydrocortisone (hydrocortisone sodium phosphate) 1st line choice of injection 1) The quickest way to open the syringe and needle is to push through the paper. 2) Tap the hydrocortisone ampoule to remove liquid from the top, the dot is where to break it open. 3) Push firmly to attach the needle to the syringe and carefully remove the shield. 4) Hold the ampoule with your nondominant hand and draw up with other. 5) Hold the syringe at eye level, check for bubbles by gently tapping the barrel. Expel any air by pressing the plunger until a drop of liquid forms at the top of the needle. 6) Ideally the injection should not be through a layer of clothing so it is advisable to bare the skin of the target site. The best site is in to the middle third of the outside of the thigh for this intramuscular injection. If giving yourself the injection, you need to inject yourself on the same side. e.g. right hand, right thigh. 7) Stretch the skin slightly with your non-dominant hand; hold the syringe like a dart in your dominant hand. Insert the needle swiftly and firmly and at an angle of 90 degrees. Push the needle in completely. Depress the plunger steadily until it is empty. Quickly and swiftly remove the needle and apply a swab or tissue until bleeding stops. Please remember to dispose of the needle carefully. Produced with the kind permission of the Addison s Disease Self Help Group http://www.adshg.org.uk April 2004 page 4 of 8
Adrenal Deficiency of Cortisol How to give an emergency injection of hydrocortisone (hydrocortisone sodium succinate) 2nd line choice of injection if hydrocortisone sodium phosphate is not available 1) The quickest way to open the syringe and needle is to push through the paper. Screw the needle (still in its guard) onto the end of the syringe. 3) Remove the guard from the needle and draw up the water from the ampoule into the syringe. 2) Flip off the top of the hydrocortisone vial. Tap the top of water ampoule to remove liquid from the top. Snap off the top (the dot indicates where it will snap most easily). 4) Inject the water through the rubber bung into the hydrocortisone vial. Mix well by gently shaking. 5) Keeping the point of the needle through the rubber bung but below the surface of the liquid. Draw up reconstituted hydrocortisone into the syringe. 6) Hold the syringe upright at eye level, as shown and tap to get any air bubbles to the top. Expel any air by gently pushing up the plunger until a drop of liquid forms at the top of the needle. 7) The best site is the outer part of the middle third of the thigh for this intramuscular injection. Stretch the skin slightly with your nondominant hand; hold the syringe like a dart with your dominant hand and insert the needle at 90 (right angles). Push the needle in completely. Depress the plunger of syringe gently but firmly until all the contents of the syringe are injected. Quickly remove the needle and apply a swab or tissue until bleeding stops. Please remember to dispose of the needle carefully. Produced with the kind permission of the Addison s Disease Self Help Group http://www.adshg.org.uk April 2004 page 5 of 8
Glucocorticoid medication guidelines for surgical/dental procedures for Adrenal insufficient patients Type of procedure Lengthy, major surgery with long recovery time eg open heart surgery, major bowel surgery, procedures needing ITU Major surgery with rapid recovery eg caesarean section, joint replacement Labour and vaginal birth Minor surgery eg cataract surgery, hernia repairs, laparoscopy with local anaesthetic Invasive bowel procedures requiring laxatives eg colonoscopy and barium enemas Other invasive procedures eg gastroscopy Minor procedure eg skin mole removal with local anaesthetic Major dental surgery with general anaesthetic eg dental extraction Dental surgery with local anaesthetic eg root canal work Pre-operative and operative needs 100mg hydrocortisone i.m just before anaesthesia. 100mg hydrocortisone i.m just before anaesthesia. 100mg hydrocortisone i.m at onset of labour. Continue i.m if labour prolonged. 100mg hydrocortisone just before anaesthesia. Hospital admission overnight with i.v fluids and 100mg hydrocortisone i.m during preparation. 100mg hydrocortisone just before commencing procedure. 100mg hydrocortisone just before commencing procedure. Normal daily dose. 100 hydrocortisone i.m just before commencing. Double oral dose (up to 20mg) one hour prior to procedure. Reproduced with kind permission of the Addison's Disease Self Help Group 2006 Post-operative needs Continue 100mg hydrocortisone i.m every 6 hours until able to eat and drink normally (discharged from ITU). Then double oral dose for 48+ hours. Then taper down until on normal dose. Continue 100mg hydrocortisone i.m every 6 hours for 24-48 hours (or until eating/drinking normally). Then double oral dose for 24-48 hours. Then return to normal dose. Double oral dose for 24-48 hours after delivery. If well then return to normal dose. Double oral dose for 24 hours. Then return to normal dose. Double oral dose for 24 hours and then return to normal dose. Double oral dose for 24 hours and then return to normal dose. An extra dose orally only where hypoadrenal symptoms occur afterwards. Double oral dose for 24 hours and then return to normal dose. Double oral dose for 24 hours and then return to normal dose. Minor dental procedure Normal oral dose An extra oral dose only if hypoadrenal symptoms occur afterwards. page 6 of 8
Life-threatening condition. Information for medical staff Acute adrenal insufficiency/addisonian crisis Please give our patient immediate medical attention S/he has primary or secondary adrenal insufficiency. Without urgent medical treatment, any serious injury or illness may precipitate an adrenal crisis. This can lead to severe hypotension or life-threatening hypovolaemic shock. If in doubt, or if the patient becomes hypotensive, drowsy or peripherally shut down please arrange hospital admission. The treatment our patient requires to prevent hypovolaemic shock is: 100mg hydrocortisone every 6 hours intra muscularly or by infusion pump, e.g. 5-10mg/hr. An intravenous saline infusion. Usually, these high doses of hydrocortisone can be weaned to oral maintenance doses of hydrocortisone after 24-72 hours, provided the patient's condition is improving. Please ensure our patient is on oral steroids prior to discharge. Our patient can provide a steroid card or Medic alert to confirm their adrenal insufficiency. Our patient also has the following conditions which may require monitoring: Our patient takes the following medication: If you are unable to contact us to confirm details of our patient's medical history or require further advice on the management of adrenal insufficiency please contact a senior hospital Endocrinologist without delay. Patient's name Hospital no Date of birth / / Signature Date / / page 7 of 8
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