From the Guidelines
For this patient, hydrocortisone 100 mg IM is the recommended steroid treatment. Administer hydrocortisone 100 mg intramuscularly immediately, followed by 50-100 mg every 6-8 hours as needed, as suggested by the consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency 1, 2. Monitor the patient's symptoms and vital signs closely.
Rationale for Hydrocortisone
Hydrocortisone is preferred over other steroids in this case because:
- It's the same medication the patient usually takes orally, minimizing potential side effects or interactions.
- Hydrocortisone has both glucocorticoid and mineralocorticoid effects, which is crucial for a patient with adrenal insufficiency.
- The dosing is more flexible and can be easily adjusted based on the patient's response.
Treatment Approach
After the initial IM dose, transition to IV hydrocortisone if the patient remains unable to tolerate oral medication. Once the patient can take oral medications, resume their usual oral hydrocortisone regimen. It is also essential to educate the patient on the importance of having an emergency hydrocortisone injection kit for similar situations in the future and ensure they understand how to use it, as highlighted in the management of acute adrenal insufficiency 2.
Key Considerations
In managing this patient, it's crucial to consider the potential for acute adrenal crises, which can be precipitated by events such as vomiting, infections, or surgical procedures, as noted in the consensus statement 1. Therefore, prompt recognition and appropriate therapy are vital to prevent morbidity and mortality. The patient's quality of life can be significantly improved by proper management of their condition, including education on self-medication during intercurrent illnesses and the use of emergency hydrocortisone injection kits.
From the FDA Drug Label
When employed as a temporary substitute for oral therapy, a single injection during each 24-hour period of a dose of the suspension equal to the total daily oral dose of MEDROL® Tablets (methylprednisolone tablets, USP) is usually sufficient The suitable intramuscular (IM) steroid for a 53-year-old female with adrenal insufficiency, taking daily hydrocortisone, who presents with nausea, vomiting, and flank pain, and is unable to tolerate oral (PO) intake is methylprednisolone (IM), with a dose equal to the total daily oral dose of hydrocortisone, as a single injection during each 24-hour period 3.
From the Research
Suitable Intramuscular (IM) Steroid
For a 53-year-old female with adrenal insufficiency, taking daily hydrocortisone, who presents with nausea, vomiting, and flank pain, and is unable to tolerate oral (PO) intake, the following options can be considered:
- Methylprednisolone sodium phosphate can be administered intramuscularly, as it has been shown to have a similar effect to methylprednisolone sodium succinate in terms of eosinophil suppression, elevation of glucose, and white blood count differential shifts 4.
- The intramuscular route of administration of methylprednisolone sodium phosphate has been found to be well-tolerated in healthy volunteers, with no significant changes in vital signs, standard hematology, and clinical chemistry parameters 4.
Pharmacokinetics and Clinical Response
- The relative oral bioavailability of methylprednisolone is 69.2%, and elimination is prolonged when given orally compared to intravenous administration 5.
- Clinical response to pulse steroid therapy has been found to be no different with respect to route of administration, whether oral or intravenous 5.
Comparison of Intravenous and Oral Glucocorticoid Therapy
- Oral prednisone therapy has been found to be as effective as intravenous methylprednisolone sodium succinate for the treatment of asymptomatic cardiac rejection, with similar infectious complication rates and lower cost 6.
- A single intra-articular or intramuscular injection of methylprednisolone acetate can decrease cortisol levels, with a significant decrease in serum cortisol levels 24 hours after intra-articular injection and 72 hours after intramuscular injection 7.