The Use of Corticosteroids in Adrenal Insufficiency

The World Health Organization has recently advised against corticosteroids use in COVID-19 patients, unless indicated for another reason, as in adrenal insufficiency (AI). Indeed, both patients with primary or secondary AI are at higher risk of developing infections, precipitating an adrenal crisis. No specific protocol has been studied for AI patients in the context of COVID-19. However, here is a summary of experts’ consensus.

Prevention

1. AI patients should respect strict social distancing. Consequently, work from home is strongly preferred.

2. Extra prescription for regular and emergency hydrocortisone should be provided. Ensure that the patient is wearing a medical bracelet or a steroid emergency card.

3. During the pandemic, routine blood checks in healthy AI patients are not necessary but regular follow-ups by telephone or videoconferencing are still recommended.

Treatment

1. The increase of glucocorticoids doses depends on the severity of the disease. The following recommendations apply to adults and adolescents.

a) In adults, mineralocorticoid replacement is no longer needed when daily dose of hydrocortisone exceeds 50 mg.

b) There is currently no consensus whether increased corticosteroid dosing should respect circadian rhythm or should be delivered steadily throughout the day in milder stages of infection.

Asymptomatic COVID-19 infected AI patients	Usual dosage
Mild symptoms (fever, cough)	Double the replacement dose if > 38oC, triple if > 39oC Increase electrolyte-containing fluids as tolerated If oral intake non-tolerated, hydrocortisone 100 mg intramuscularly (IM) or intravenously (IV)
Suspected pneumonia (persistent cough, respiratory rate > 30 breaths/min, severe respiratory distress, oxygen saturation ≤ 93% on room air or hypotension)	Hydrocortisone 100 mg IM or IV followed by 60 mg/day infusion  Consider hydrocortisone 50 mg orally every 6 hours if not hospitalized Isotonic saline infusion
Acute respiratory distress syndrome (ARDS)	50-100 mg IV followed by 200mg/day infusion of hydrocortisone Respect of circadian rhythm is no longer relevant Isotonic saline infusion

2. In children:

a) If mild symptoms, doses should be doubled (if > 38oC) or tripled (if > 39oC) and administered orally every 6 hours. If unable to tolerate oral intake, hydrocortisone IM 50 mg/m2. 

b) If acute and more severe infection, parenteral injection of 50-100 mg/m2 followed by 50mg/day for infants or 100 mg/day for school children split into 4 equal doses every 6 hours.

3. Given the coagulation abnormalities associated with the use of higher doses of corticosteroids, heparin should be initiated early during hospitalization (e.g. 4000 U every 12h).

These data come from the guidelines of the American, Italian and European Societies of Endocrinology.

Sources

1. Arlt, W., Baldeweg, S. E., Pearce, S. H. S., & Simpson, H. L. (2020). Endocrinology in the time of COVID-19: Management of adrenal insufficiency. European Journal of Endocrinology of the European Federation of Endocrine Societies. https://doi.org/10.1530/eje-20-0361 

Experts consensus of the European Society of Endocrinology

2. Isidori, A. M., Arnaldi, G., Boscaro, M., et al. (2020). COVID-19 infection and glucocorticoids: update from the Italian Society of Endocrinology Expert Opinion on steroid replacement in adrenal insufficiency. Journal of Endocrinological Investigation, 1-7. https://doi.org/10.1007/s40618-020-01266-w

Experts consensus of the Italian Society of Endocrinology

3. R. Bornstein, S., Allolio, B., Arlt, W., et al., Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism., https://doi.org/10.1210/jc.2015-1710 

 

 

Clinical guidelines for the diagnosis and treatment of primary adrenal insufficiency from the Endocrine Society