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Addison’s disease: patient-administered stress dosing not always used effectively

By Bianca Nogrady
A proportion of people with Addison’s disease do not manage glucocorticoid dose escalation effectively during periods of physiological stress, Australian research has found.

Writing in the Journal of the Endocrine Society, researchers presented results of an audit of 252 episodes of hospital treatment in 56 patients with treated Addison’s disease, presenting to a large regional hospital.

All patients were on glucocorticoid therapy, but 66.1% had no record of using any stress dosing – increasing medication dose during illness such as acute infection – before any of their hospital attendances.

In only 45 (17.9%) of the episodes of hospital care had the patient used any form of dose escalation before presenting to hospital.

Patients with adrenal insufficiency are advised to double or triple their oral glucocorticoid dose during illness, but in the case of diarrhoea or vomiting – where the oral dose may not be absorbed – they are advised to administer an intramuscular injection and seek medical treatment.

In this study, 120 (47.6%) presentations involved vomiting, but only in 27.5% of these had the patient used any form of dose escalation and only in five cases was intramuscular hydrocortisone used.

Researchers noted that older patients were less likely to undertake dose escalation, whereas individuals who had experienced more hospital presentations in the past were more likely to use dose escalation before hospital attendance.

Study coauthor and medical epidemiologist Professor Louise Rushworth, from the University of Notre Dame, Sydney, said the study was prompted by the observation that the incidence of adrenal crises had been increasing in Australia, and researchers were keen to examine whether there were any preventable factors contributing to this increase.

‘There is evidence to suggest that even when patients have been given education, stress dosing may not be used appropriately,’ Professor Rushworth told Endocrinology Today.

However, she suggested that more targeted education and support of patients with Addison’s disease, such as young people presenting with vomiting, could potentially increase understanding and awareness of correct stress dosing.
J Endocrine Soc 2019; doi: 10.1210/js.2019-00263.