Background: Adrenal crises (AC) cause morbidity and mortality in patients with Addison’s disease (primary adrenal insufficiency (PAI)). Patient-initiated oral stress dosing, with parenteral hydrocortisone for those unable to take tablets, is recommended to avert ACs. While these should be effective, the continued incidence of ACs remains largely unexplained.
Methods: An audit of all attendances between 2000 and 2017 by adult patients with treated PAI to one regional referral centre in New South Wales, Australia. Measurements were those taken on arrival at hospital.
Results: There were 252 attendances by 56 patients with treated PAI during the study period. Women comprised 60.7% (n=34) of the patients. Mean age of attendees was 53.7 (19.6) years. The majority (83.7%, n= 211) of patients were admitted. Nearly half (45.2%, n=114) the patients had an infection. Among the 252 attendances, there were 61 (24.2%) ACs diagnosed by the treating clinician. Only 17.9% (n=45) of the hospital presentations followed any form of stress dosing. Intramuscular (IM) hydrocortisone was used before 7 (2.8%) attendances only and no subcutaneous (SC) administration of hydrocortisone was recorded. Among patients with a clinician diagnosed AC, only 32.8% (n=20) had used stress dosing before presentation. Vomiting was reported by 47.6% (n=120) of the patients on arrival but only 33 (27.5%) of these attempted stress dosing and only 5 patients with vomiting used IM hydrocortisone. In 11 attendances, a diagnosis of diabetic ketoacidosis was recorded. There were 5 (2.0%) in-hospital deaths. Younger age, vomiting and the number of prior presentations all significantly predicted stress dose use (p<0.05).
Conclusion: Dose escalation strategies are not used universally or correctly by all acutely unwell patients with PAI, and many patients do not use IM or SC hydrocortisone injections. Previous treatment in hospital increases the likelihood of stress dosing and offers the opportunity for reinforcement of prevention strategies.