Provide Glucocorticoid Injection Kit for Emergency Use and Training on Administration

STEP 1 — Gather Information

Confirm diagnosis of PAI via low cortisol with elevated ACTH or failed ACTH stimulation test; review current glucocorticoid and mineralocorticoid doses; assess patient age, cognitive status, and ability to perform self‑injection; verify presence of steroid emergency card and medical alert jewelry.

STEP 2 — Rule In / Rule Out

Rule in if PAI is confirmed and the patient is at risk for adrenal crisis (e.g., prior crisis, intercurrent illness, pregnancy, or planned stressors); rule out if PAI is excluded or the patient lacks capacity for self‑injection and no trained caregiver is available.

STEP 3 — Classify or Stratify

Stratify by age and caregiver availability: adults and adolescents who can self‑inject receive a kit for self‑use; young children or those with cognitive impairment receive a kit designated for caregiver administration.

STEP 4 — Decide

Prescribe a hydrocortisone sodium succinate 100 mg vial with syringe and alcohol swabs, provide a written sick‑day rule sheet, demonstrate IM or SC injection technique, issue or update steroid emergency card and medical alert bracelet, and schedule reinforcement training at each follow‑up visit.

Clinical Guardrails / Mimics / Pitfalls

Do not delay kit issuance pending specialist referral; do not rely on oral dosing alone during suspected adrenal crisis; avoid dexamethasone as first‑line emergency glucocorticoid because it lacks mineralocorticoid activity; ensure patient knows to inject immediately for fever > 38°C, persistent vomiting, trauma, or inability to retain oral meds; do not substitute kit with suppositories unless vomiting precludes injection and suppositories are available.

Concrete Clinical Example

A 34‑year‑old woman with newly diagnosed autoimmune PAI is started on hydrocortisone 20 mg morning, 10 mg evening and fludrocortisone 0.1 mg daily. At the initiation visit, PAI is confirmed, she is taught to self‑inject 100 mg hydrocortisone IM, receives an emergency kit, steroid card, and instruction to double her oral dose for fever > 38°C and to inject if she cannot keep pills down.

Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710