Educate patients on stress-dose and emergency glucocorticoid administration
STEP 1 — Gather Information
Confirm diagnosis of adrenal insufficiency (AI), current glucocorticoid regimen and dose, assess prior education on stress dosing, and identify any history of adrenal crisis or risk factors.
STEP 2 — Rule In / Rule Out
If patient has confirmed AI (primary or secondary), proceed; if not AI, stress-dose education is not indicated.
STEP 3 — Classify or Stratify
Classify stress scenarios: minor illness (fever, vomiting) requiring 2-3x usual oral GC dose; major stress (surgery, severe illness) requiring immediate parenteral 50-100 mg hydrocortisone; instruct patient to recognize symptoms necessitating emergency GC (e.g., inability to retain oral meds, hypotension, severe vomiting).
STEP 4 — Decide
Provide patient with written emergency plan, prescribe emergency kit containing injectable high-dose glucocorticoid (e.g., 100 mg hydrocortisone vial with syringe), instruct to obtain and wear medical identification (card/bracelet/necklace) stating AI, and demonstrate self-administration technique.
Clinical Guardrails / Mimics / Pitfalls
Do not delay emergency GC administration during suspected adrenal crisis; avoid relying solely on oral dosing if patient is vomiting or unconscious; ensure patient knows not to substitute with other steroids without medical advice; periodically review kit expiration and replace as needed.
Concrete Clinical Example
A 50-year-old man with secondary AI after craniopharyngioma resection, on hydrocortisone 10 mg AM/5 mg PM, receives stress-dose education, is given a MedicAlert bracelet, prescribed a 100 mg hydrocortisone IM kit, and taught to administer IM if unable to retain oral meds during flu.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Maria Fleseriu et al., 2016, DOI:10.1210/jc.2016-2118