What is the appropriate management for a patient with primary or secondary adrenal insufficiency, such as Addison's disease, who is on a daily steroid replacement regimen and requires hydrocortisone (cortisol) for home use during periods of increased stress or potential adrenal crisis?

Hydrocortisone 100mg Emergency Kit for Home Use in Adrenal Insufficiency

Every patient with primary or secondary adrenal insufficiency must be prescribed an emergency injectable hydrocortisone 100 mg kit for home use, with training provided to both the patient and family members on self-administration during impending adrenal crisis. 1, 2, 3, 4

Rationale for Emergency Home Hydrocortisone

• Adrenal crises occur at a rate of 6-8 episodes per 100 patient-years, with a mortality rate of 0.5 per 100 patient-years when treatment is delayed. 1, 4
• Infections, particularly gastroenteritis with vomiting, are the most common precipitating causes and can rapidly progress to life-threatening crisis within hours. 1, 4, 5
• Patients who cannot access emergency medical care within 30-60 minutes require the ability to self-administer parenteral hydrocortisone to prevent death. 1, 4, 5

When to Use the Emergency 100mg Injection

Administer the 100 mg hydrocortisone injection immediately if the patient experiences:

• Persistent vomiting or severe diarrhea preventing oral medication absorption 1, 4, 5
• Severe weakness, confusion, or altered mental status 1, 3
• Hypotension with lightheadedness or loss of consciousness 1, 3
• High fever (>38.5°C/101°F) with inability to tolerate oral hydrocortisone 1, 4
• Any situation where oral stress dosing fails to control symptoms within 2-4 hours 1, 4

Administration Protocol

• The 100 mg hydrocortisone should be administered intramuscularly or intravenously if the patient or family member has been trained. 1, 4
• After injection, immediately call emergency services (911) and inform them the patient has adrenal insufficiency and has received hydrocortisone. 1, 2, 3
• Transport to the emergency department is mandatory even after home injection, as additional IV hydrocortisone (200 mg/24 hours) and IV saline resuscitation are required. 1, 3, 4

Sick Day Rules: Oral Stress Dosing Before Crisis

Patients should double or triple their usual oral hydrocortisone dose during:

• Febrile illness (temperature >38°C/100.4°F): double the daily dose 1
• Moderate illness (severe cold, flu, gastroenteritis without vomiting): double to triple the daily dose 1, 2
• Minor surgical procedures or dental work: 50-75 mg hydrocortisone on the day of procedure 2
• Major surgery: 100 mg IV hydrocortisone at induction, followed by 200 mg/24 hours as continuous infusion 1

Critical Patient Education Components

• All patients must wear a medical alert bracelet or necklace stating "adrenal insufficiency" to trigger immediate stress-dose corticosteroids by emergency personnel. 1, 2, 3
• Patients and family members must receive hands-on training in preparing and administering the emergency injection, with periodic refresher training. 1, 4, 5
• Provide written instructions (steroid emergency card) that the patient carries at all times, detailing their diagnosis, daily dose, and emergency management. 1, 2
• Establish 24-hour access to an endocrinologist or on-call physician for telephone consultation during illness. 5

Common Pitfalls to Avoid

• Never delay emergency hydrocortisone injection while attempting oral stress dosing if the patient is vomiting or severely ill—this delay can be fatal. 1, 3, 4, 5
• Do not rely on prednisone suppositories (vaginal or rectal) as emergency treatment—pharmacokinetics are inadequate and unreliable compared to parenteral hydrocortisone. 6
• Patients with primary adrenal insufficiency require both glucocorticoid AND mineralocorticoid replacement (fludrocortisone 0.05-0.2 mg daily), but mineralocorticoid is NOT needed during acute crisis management as high-dose hydrocortisone provides sufficient mineralocorticoid activity. 1, 3, 7
• Educate patients that "feeling unwell" with nausea, malaise, or orthostatic symptoms warrants immediate stress dosing—waiting for severe symptoms increases mortality risk. 1, 4

Maintenance Therapy Context

• Standard maintenance dosing is hydrocortisone 15-25 mg daily in divided doses (typically 10 mg morning, 5 mg noon, 2.5-5 mg afternoon) to mimic physiological cortisol rhythm. 1, 2, 8, 7
• The 100 mg emergency dose represents 4-7 times the daily maintenance dose and is appropriate for life-threatening stress. 1, 3, 8, 4
• After emergency injection and hospital treatment, stress dosing is tapered over 3-5 days back to maintenance therapy once the precipitating illness resolves. 1, 3