Individuals with adrenal insufficiency who are treated with appropriate replacement with glucocorticoids (cortisol, cortisone, prednisone) and mineralocorticoid (Florinef) can lead normal active lives. The adrenal gland responds to the stresses we experience on a daily basis by increasing the output of cortisol in keeping with the degree of stress.
Individuals whose adrenal glands are not working (adrenal insufficiency) must "do the thinking" for their adrenals and vary the dose of glucocorticoid in situations where added stress is experienced. These stresses can be physical or emotional. The increase in the dose of glucocorticoid should relate to the degree of stress (one half tablet for a mild cold, double the daily dose for a more severe infection). The dose of Florinef can generally remain the same, but since we tend to excrete more salt when we have a fever, foods containing salt such as soups are helpful.
Situations in which individuals with adrenal insufficiency are unable to retain their medication present a more difficult problem and it is important to be well prepared.
- All individuals with adrenal insufficiency should have a Medic-Alert bracelet or necklace stating the diagnosis and that in an emergency intravenous cortisol (Solu-Cortef) is required.
- It is helpful to carry a short note from your family doctor stating the diagnosis and the need for intravenous Solu-Cortef and saline (intravenous salt solution).
If an individual with adrenal insufficiency is unable to retain their medication for longer than 4 to 6 hours, they should:
- Call their family doctor to tell her/ him that they are ill and are going to the emergency department and ask their doctor to call ahead to the department to suggest appropriate treatment.
- Go to the emergency department:
- to receive intravenous Solu-Cortef and saline
- to be seen by the emergency physician to determine the cause of the acute situation. This may require additional investigation and treatment for this underlying illness
Situations may arise in which individuals with adrenal insufficiency will find it difficult to get to a hospital or see a physician. This can occur when traveling or at a summer cottage. Under these conditions it a good idea to have an emergency kit which will provide temporary help. There is no specific kit available, but the components can be readily obtained from any pharmacy, with a prescription from your family doctor. The components consist of:
- Solu-Cortef Act-o-vial 100mg
- 3ml syringe
- 22 G needle
- Alcohol swabs
The Act-o-vial contains the soluble cortisol in a dry powder in one compartment and sterile water in a second compartment. The instructions for mixing, come with the package and are easy to follow. After mixing, the solution is drawn into the syringe through the needle. Air in the syringe can be expelled by holding the syringe with the needle pointing up and pushing up on the plunger until the air bubble is expelled. The contents of the syringe can then be injected into a muscle — preferably the upper outer quadrant of the buttock, by a family member or friend. The effect of the intramuscular injection will not be as rapid as the intravenous injection but should be effective within 30 minutes to one hour.
It should be emphasized that this emergency kit should only be used if there will be a delay in getting to a health care facility. This treatment does not provide the fluid replacement which is usually required and does not treat the underlying problem which precipitated the acute situation. Therefore it is not a substitute for getting medical attention.
Submitted by Dr. Donald Killinger, MD, PhD, FRCPC
Medical Advisor, Canadian Addison Society