What to do if a patient with adrenal insufficiency misses their medication for 5 days?

Management of Adrenal Insufficiency After 5 Days Without Medication

A patient with adrenal insufficiency who has gone without their medication for 5 days should be treated as an adrenal crisis requiring immediate administration of 100 mg IV hydrocortisone, fluid resuscitation with normal saline, and hospital admission. 1

Immediate Management

1. Adrenal Crisis Treatment:

   • Administer hydrocortisone 100 mg IV immediately 1
   • Begin fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 1
   • Continue hydrocortisone 50-100 mg IV every 6 hours or as a 200 mg/day continuous infusion until stabilized 1, 2

2. Vital Signs and Monitoring:

   • Monitor blood pressure, heart rate, and electrolytes closely
   • Watch for signs of shock, hypotension, fever, altered mental status, and electrolyte abnormalities (particularly hyponatremia and hyperkalemia in primary adrenal insufficiency) 1

Hospital Management

• Continue IV hydrocortisone until the patient is hemodynamically stable and can tolerate oral medications 1
• Monitor serum electrolytes, particularly sodium and potassium levels 3
• For patients with primary adrenal insufficiency, mineralocorticoid replacement with fludrocortisone should be resumed once oral medications are tolerated 3
• Investigate and treat any precipitating factors (infections are common triggers) 4

Transition Back to Maintenance Therapy

• Once stabilized, transition to oral glucocorticoid replacement therapy 1
• Start with 2-3 times the usual maintenance dose and taper over 5-10 days to the patient's regular maintenance dose 1
• For typical maintenance, hydrocortisone 10-30 mg daily in divided doses or equivalent prednisone 5-10 mg daily 1

Patient Education Before Discharge

Missing medication for 5 days represents a serious gap in patient education. Before discharge, ensure:

• Patient understands the life-threatening nature of adrenal insufficiency 1
• Patient is educated on stress dosing during illness 1
• Patient has an emergency injectable steroid kit and knows how to use it 1
• Patient wears a medical alert bracelet/card for adrenal insufficiency 1
• Patient understands when to seek immediate medical attention 4

Common Pitfalls to Avoid

1. Delayed Treatment: Never delay administration of glucocorticoids when adrenal crisis is suspected - treat first, investigate later 2
2. Inadequate Fluid Resuscitation: Patients are often significantly volume depleted 1
3. Failure to Identify Triggers: Gastrointestinal illness is the most common precipitant for adrenal crisis (30-50% of cases) 5
4. Insufficient Patient Education: Patients must understand the importance of never missing doses and how to adjust medication during illness 1
5. Inadequate Follow-up: Arrange close follow-up to ensure proper medication adherence and to reinforce education 6

Missing 5 days of adrenal replacement therapy is a serious medical emergency that requires immediate intervention to prevent mortality. The key to successful management is prompt recognition, immediate treatment with high-dose glucocorticoids and fluids, followed by appropriate transition back to maintenance therapy and comprehensive patient education.