Educate adrenal insufficiency patients on enzyme-inducing antiepileptic drugs about early AI signs
STEP 1 — Gather Information
Confirm adrenal insufficiency diagnosis, verify current glucocorticoid regimen (nondexamethasone), identify newly prescribed enzyme-inducing AED, assess baseline symptoms.
Action: If patient meets criteria, proceed to Step 2.
STEP 2 — Rule In / Rule Out
Determine if the patient is on nondexamethasone GC and has started an enzyme-inducing AED (e.g., phenytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone).
Action: If yes, proceed to Step 3; if no, no further education needed.
STEP 3 — Classify or Stratify
Assess baseline cortisol replacement adequacy and recent symptoms; classify as stable AI patient requiring education on early AI signs.
Action: Proceed to structured patient education.
STEP 4 — Decide
Provide education on early AI signs (fatigue, weakness, nausea/vomiting, abdominal pain, hypotension, hyponatremia, hypoglycemia) and instruct patient to contact clinician or seek emergency care if symptoms develop; review stress-dose guidelines.
Action: Document education and schedule follow-up.
Clinical Guardrails / Mimics / Pitfalls
Do not delay education until symptoms appear; do not assume patient recognizes subtle signs; do not overlook drug interactions that may reduce glucocorticoid efficacy; do not forget to advise about emergency injectable glucocorticoid kit.
Concrete Clinical Example
A 34-year-old woman with secondary AI on hydrocortisone 15 mg AM/5 mg PM starts carbamazepine for focal seizures; clinician educates her about early AI signs; two weeks later she reports mild nausea and fatigue, contacts clinic, receives stress-dose hydrocortisone, avoids adrenal crisis.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, 10.1210/jc.2016-2118