Keywords
adrenal insufficiency - glucocorticoid - healthcare professionals - patients - steroids
Introduction
Exogenous glucocorticoid (GC) supplementation is known to cause secondary hypoadrenalism
by suppressing hypothalamic–pituitary–adrenal (HPA) axis.[1] This can lead to decreased production of both corticotropin-releasing hormone from
the hypothalamus and adrenocorticotropic hormone from the pituitary gland, leading
to a low serum cortisol level.[2]
The most common cause of cortisol deficiency is sudden stoppage of exogenous GC.[3] Patients taking 5 mg prednisolone or equivalent oral doses of GC for longer than
4 weeks are at risk of HPA axis suppression and adrenal crisis if physiologically
stressed, for instance, during acute illness, surgery, or other invasive procedures.[4]
The use of systemic GCs is 1 to 3% of the general population.[5]
[6]
[7]
[8] A systematic review and meta-analysis found that the absolute risk of adrenal insufficiency
induced by oral GCs was 48.7%, with the highest risk in people with hematologic malignancies
(60%), followed by patients with a history of renal transplant (56.2%), inflammatory
bowel disease (52.2%), and rheumatologic disorders (39.4%).[9]
Patients with adrenal insufficiency are at risk of developing life-threatening adrenal
crisis if GCs are reduced or stopped abruptly, or if GC dose is not adjusted during
periods of increased stress (e.g., illness, trauma, or surgery). Acute adrenal crisis
is a medical emergency and can present with hypotension, shock, and hyponatremia in
90% of patients. It requires urgent treatment with hydrocortisone. The healthcare
workers not always realize the urgency of treatment for acute adrenal crisis or fail
to heed the requests of well-informed patients for hydrocortisone.[10]
[11]
The adrenal crises should be preventable with education of patients and healthcare
professionals (HCPs). However, studies show significantly low awareness in both the
groups,[12]
[13] leading to failure to increase steroids during “stress” and potentially an adrenal
crisis. Knowledge about “sick-day” rules, the importance of “steroid cards,” and the
utility of parenteral steroids is shown to be suboptimal.[14]
[15]
Methods
This study was aimed at assessing the knowledge of sick-day rules in patients on long-term
GC as well as HCPs and implementing quality improvement measures at our district general
hospital (Noble's hospital) in Isle of Man, United Kingdom.
Patients aged above 18 years on long-term steroids presenting to the endocrinology
clinic over 6 weeks were included after audit-committee approval.
Patient questionnaire ([Table 1]) had questions on steroid emergency card, medic alert bracelet, receipt of sick-day
rule information, accessibility to emergency hydrocortisone-kit, and awareness of
sick-day rules. HCPs at Nobles hospital including foundation-year doctors, senior
house officers, specialty registrars, and staff nurses were surveyed ([Table 2]) on awareness of steroid emergency card, knowledge of emergency parenteral steroid
use at home, steroid dosage during acute illness, and ability to access sick-day rule
information on intranet.
Table 1
Patient questionnaire
|
Do you take STEROIDS for a medical condition?
|
|
1. Do you regularly carry a “steroid card” with you?
|
|
2. Do you wear a medic-alert bracelet that identifies you as someone who takes steroids?
|
|
3. Have you received any instructions about “sick-day rules” for steroids from your
doctor/HCP team?
|
|
4. What you will do to your steroid daily dose if you develop fever, chest infection,
or urine infection
|
|
5. What you will do to your steroid dose if you are feeling nauseous?
|
|
6. What you will do if you start vomiting?
|
|
7. Do you have a hydrocortisone emergency kit?
|
Abbreviation: HCP, healthcare professional.
Table 2
Healthcare professional questionnaire
|
1. What is your current role?
|
|
FY1 FY2 SHO StR SN others............
|
|
2. Do you know the criteria for which patients should be issued with a steroid card?
|
|
3. Have you ever given advice to patients about “sick-day rules” when starting long-term
steroid treatment?
|
|
4. How confident do you feel about giving advice on “sick-day rules” for patients
taking long-term steroids?
|
|
5. What is your current knowledge of “sick-day rules” in steroid therapy?
|
|
6. Do you, or have you ever recommended parenteral steroids for emergency home use?
|
|
7. Do you know where to access advice on sick-day rules on the hospital intranet?
|
Abbreviations: FY1, foundation year 1; SHO, senior house officer; SN, staff nurses;
StR, specialty registrars.
As a service improvement/audit project, only verbal consent was obtained from all
participants.
Results
We assessed 18 consecutive patients in total, in which only 66% (12/18) carried their
steroid emergency card, 27% (5/18) wore a medic alert bracelet, and 61% (11/18) of
patients said that they have received information about sick-day rules from an HCP.
Only 38% (7/18) had access to emergency hydrocortisone-kit. Forty-four percent (8/18)
patients were aware of steps to be taken in response to an acute infection and 11%
(2/18) were aware of appropriate response to vomiting ([Table 3]).
Table 3
Patients questionnaire response
|
Parameter
|
Percentage/number of patients
|
|
Carried their steroid emergency card
|
66% (12/18)
|
|
Wore a medic alert bracelet
|
27% (5/18)
|
|
Patients said that they have received information about sick-day rules
|
61% (11/18)
|
|
Had access to emergency hydrocortisone-kit
|
38% (7/18)
|
|
Patients were aware of steps to be taken in response to an acute infection
|
44% (8/18)
|
|
Appropriate response to vomiting
|
11% (2/18)
|
We assessed 36 HCPs and their responses were anonymized, and 36% (13/36) were aware
of steroid emergency card. Only 11% (4/36) HCPs had knowledge of emergency use of
parenteral steroids at home, 50% (18/36) HCPs exhibited awareness regarding steroid
dose during acute illness, and 27% (10/36) HCPs were aware of accessible hospital
intranet resources ([Table 4]).
Table 4
HCPs questionnaire response
|
Parameter
|
Percentage/number of HCPs
|
|
Aware of steroid emergency card
|
36% (13/36)
|
|
Knowledge of emergency use of parenteral steroids at home
|
11% (4/36)
|
|
Awareness regarding steroid dose during acute event
|
50% (18/36)
|
|
Awareness of accessible hospital intranet resources
|
27% (10/36)
|
Abbreviation: HCPs, healthcare professionals.
The study has limitations due to small number of patients and HCPs were recruited,
as it was performed in a small district general hospital.
Discussion
Our study has revealed significant gaps in knowledge about safety aspects of long-term
GC therapy among patients and HCPs.
A survey by Kate et al has also shown similar results with lack of awareness about
different aspects of safe usage of supra-physiological doses of GC among both the
groups. Only 20% of patients received instructions about “sick-day” rules from HCP,
2% had access to parenteral steroids at home, and 68% were unaware of precautions
to take in the context of minor and major stress. Of the HCP group, 46% advised patients
about “sick-day” rules at the start of treatment, 42% recommended parenteral steroids
for emergency home use, and 12% responded that they have not recommended increasing
steroid dosage during “stress.”[15] In another survey in rheumatology practice during coronavirus disease 2019 (COVID-19)
wave, only 50% HCPs always or usually counseled patients about corticosteroid sick-day
rules, and 28% did this rarely or never.[16]
Adrenal crises can be easily prevented by following appropriate sick-day rules. Patients
on corticosteroids with adrenal failure should carry a medical alert bracelet and
a card stating that they take steroids daily. They need to be advised to double their
regular GC replacement dose during intercurrent illness and to alert doctors and nurses
to the need for early admission and parenteral steroid replacement during more severe
illness and surgery. It is also recommended that patients carry the emergency information
issued by the Addison's self-help group.[17]
There is a recent guidance published by Society for Endocrinology Emergency Card working
group on adrenal insufficiency and adrenal crises, entailing who is at risk and how
should they be managed.[18]
The following group of patients should be given an emergency steroid card because
of their risk of adrenal insufficiency. They should be given hydrocortisone 100 mg
when they present to hospital being unwell or during surgery/procedures.
-
1) If a patient had three or more short courses of high-dose GCs (e.g., prednisolone
40 mg daily or equivalent) within the last 12 months and for 12 months after stopping.
-
2) If a patient has three or more GC intramuscular or intra-articular injections within
the preceding 12 months and for 12 months after stopping.
-
3) Inhaled steroid therapy of fluticasone more than 500 µg/day or beclomethasone 1,000
µg/day and for 12 months after stopping.
-
4) Patient taking high-dose topical steroid (≥ 200 g/week) on large area of skin for
4 weeks and greater.
-
5) COVID-19 patients given dexamethasone for more than 10 days.
There is subgroup of patients who would need emergency steroid cards and also information
on the sick-day rules. These are the group of patients at significantly higher risk
of HPA axis suppression and accordingly adrenal insufficiency. They should be treated
with hydrocortisone if present to hospital unwell and during surgery/procedures.
-
1) Patients on oral prednisolone more than or equal to 5mg/day or equivalent doses
of other GC for more than 4 weeks and for 12 months after stopping.
-
2) Patients with chronic respiratory disease such as chronic obstructive pulmonary
disease and asthma on high-dose inhaled steroids receiving repeated courses of oral
steroids
-
3) Patients on GCs and CYP3A4 inhibitors at the same time (thus having enhanced serum
cortisol concentrations with the resultant risk of HPA axis suppression).
A home emergency kit of hydrocortisone is not routinely needed in these patients unless
there is a particular clinical concern. Also, to be aware that corticosteroids used
via multiple routes simultaneously significantly increase the risk of adrenal suppression.[18]
The study was conducted in a small district general hospital and is single centered.
The number of patients and HCP was limited due to the same reason.
Conclusion
This study revealed significant lack of awareness of sick-day rules among patients
and HCPs alike. Majority of patients failed to carry steroid emergency card or medic
alert bracelet due to compliance issues, and more than 50% lacked knowledge of sick-day
rules due to knowledge gap and explanation of the importance of the same. Most of
the HCPs were unaware of sick-day rules and available information resources.
Patients need to be advised on sick-day rules and this information should be reiterated
at every patient contact.
