Adrenal crisis steroid taper

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please  contact us .

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Hypoadrenocorticism is treated with fludrocortisone or with monthly injections of desoxycorticosterone pivlate (DOCP) and daily prednisone. Routine blood work is necessary in the initial stages until a maintenance dose is established. Most of the medications used in the therapy of hypoadrenocorticism can cause excessive thirst and urination if not prescribed at the lowest effective dose, making it important to provide enough drinking water. If the owner knows about an upcoming stressful situation (shows, traveling, etc.), patients generally need an increased dose of prednisone to help deal with the added stress.

Untreated, adrenal insufficiency is fatal, and indeed this was invariably the case until the advent of synthetic cortisone in 1949. Treatment of Addison's disease is lifelong. The prognosis for any patient with adrenal insufficiency will depend on the underlying cause. In those patients in whom the prognosis is not affected by the underlying pathology, replacement therapy should result in a return to health. However, a Norwegian study found an excess of mortality in patients diagnosed with Addison's disease at a young age, associated with acute adrenal failure, infection and sudden death. [ 16 ]

During minor illness (., flu or fever >38° C [° F]) the hydrocortisone dose should be doubled for 2 or 3 days. The inability to ingest hydrocortisone tablets warrants parenteral administration. Most patients can be educated to self administer hydrocortisone, 100 mg IM, and reduce the risk of an emergency room visit. Hydrocortisone, 75 mg/day, provides adequate glucocorticoid coverage for outpatient surgery. Parenteral hydrocortisone, 150 to 200 mg/day (in three or four divided doses), is needed for major surgery, with a rapid taper to normal replacement during the recovery. Patients taking more than 100 mg hydrocortisone/day do not need any additional mineralocorticoid replacement. All patients should wear some form of identification indicating their adrenal insufficiency status.

The clinical presentation of adrenal insufficiency is variable, depending on whether the onset is acute, leading to adrenal crisis, or chronic, with symptoms that are more insidious and vague. Therefore, the diagnosis of adrenal insufficiency depends upon a critical level of clinical suspicion. Adrenal crisis should be considered in any patient who presents with peripheral vascular collapse (vasodilatory shock), whether or not the patient is known to have adrenal insufficiency. Likewise, isolated corticotropin (ACTH) deficiency, although rare, should be considered in any patient who has unexplained severe hypoglycemia or hyponatremia. (See "Clinical manifestations of adrenal insufficiency in adults" .)

Adrenal crisis steroid taper

adrenal crisis steroid taper

During minor illness (., flu or fever >38° C [° F]) the hydrocortisone dose should be doubled for 2 or 3 days. The inability to ingest hydrocortisone tablets warrants parenteral administration. Most patients can be educated to self administer hydrocortisone, 100 mg IM, and reduce the risk of an emergency room visit. Hydrocortisone, 75 mg/day, provides adequate glucocorticoid coverage for outpatient surgery. Parenteral hydrocortisone, 150 to 200 mg/day (in three or four divided doses), is needed for major surgery, with a rapid taper to normal replacement during the recovery. Patients taking more than 100 mg hydrocortisone/day do not need any additional mineralocorticoid replacement. All patients should wear some form of identification indicating their adrenal insufficiency status.

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