Context: 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, is recommended to avert ACs. While these should be effective, the continued incidence of ACs remains largely unexplained.
Methods: Audit of all attendances between 2000 and 2017 by adult patients with treated PAI to one large 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. The mean age of attendees was 53.7 (19.6) years. Nearly half (45.2%, n=114) the patients had an infection. 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. IM hydrocortisone was used before 7 (2.8%) attendances only. 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 but only 33 (27.5%) of these attempted stress dosing and 5 patients with vomiting used IM hydrocortisone. The number of prior presentations was a significant independent predictor of use of stress doses [1.05 (1.01,1.09)].
Conclusion: Dose escalation strategies are not used universally or correctly by unwell patients with PAI, many patients do not use IM or SC hydrocortisone injections. Previous hospital treatment increases the likelihood of stress dosing and offers the opportunity for reinforcement of prevention strategies
