From the Guidelines
The woman's current hormone replacement therapy with prednisone 2.5 mg daily and fludrocortisone 0.1 mg every other day appears adequate for her Sheehan syndrome, and no changes are needed at this time based on her normal blood counts. Her hemoglobin and hematocrit values are within normal range, with her hemoglobin at 16 g/dL and hematocrit at 48.6%, along with a normal MCV of 91.9 fL, indicating she does not have anemia, which is reassuring 1. According to the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency, most patients with primary adrenal insufficiency should take 15–25 mg of hydrocortisone daily in split doses, and 50–200 µg fludrocortisone as a single daily dose 1. Although the patient's current prednisone dose is lower than the recommended hydrocortisone dose, it is still considered adequate, and the fludrocortisone dose is within the recommended range. However, she should continue regular monitoring of her hormone levels, particularly thyroid function and estrogen levels, as Sheehan syndrome typically affects multiple pituitary hormones 1. The patient should be evaluated for potential need of thyroid hormone replacement and estrogen/progesterone therapy if not already prescribed. Regular follow-up appointments every 3-6 months are recommended to assess her hormone replacement adequacy and to monitor for any new symptoms of hormone deficiencies.
Key Considerations
- Regular monitoring of hormone levels, including thyroid function and estrogen levels
- Evaluation for potential need of thyroid hormone replacement and estrogen/progesterone therapy
- Regular follow-up appointments every 3-6 months to assess hormone replacement adequacy
- Patient education on managing daily medications and situations of minor to moderate concurrent illnesses, as well as the importance of wearing Medic Alert identification jewelry and carrying a steroid/alert card 1
Medication Management
- Prednisone 2.5 mg daily for adrenal insufficiency
- Fludrocortisone (Florinef) 0.1 mg every other day for mineralocorticoid replacement
- Potential need for thyroid hormone replacement and estrogen/progesterone therapy to be evaluated 1
From the Research
Patient's Condition
The patient has Sheehan syndrome, a condition characterized by hypopituitarism due to necrosis of the pituitary gland, often caused by massive postpartum hemorrhage [ 2 ]. She is taking prednisone 2.5 mg daily and florinef 0.1 mg qod.
Medication Management
The patient's medication regimen should be reviewed systematically to ensure that it is not creating more problems than it solves [ 3 ]. This includes examining all medications being taken, noting history of adverse effects, need for the drug, duplication in therapy, inappropriate dose, route, or schedule, current adverse effects, drug-drug interactions, and drug-disease interactions.
Potential Issues with Current Medication
- The patient is taking prednisone, which may interfere with thyroxine treatment [ 4 ].
- Glucocorticoid deficiency can lead to hypoglycemia, hypotension, and electrolyte disorders, and acute glucocorticoid deficiency under stress is very dangerous [ 5 ].
- The patient may be at risk for coronary atherosclerotic disease due to Sheehan's syndrome [ 5 ].
Importance of Adherence
Medication adherence is crucial for the success of treatment, especially in patients with multimorbidity who take multiple medications [ 6 ]. Non-adherence can be costly for the health service and may be intentional or non-intentional, with many factors affecting an individual's compliance with a medication regimen.
Key Considerations
- The patient's medication regimen should be simplified and optimized to ensure adherence and minimize potential interactions [ 3 ].
- The patient should receive interdisciplinary endocrinologist management to ensure proper management of Sheehan's syndrome and related conditions [ 5 ].
- The patient's health professional should interact with them to understand the reason for non-adherence and promote adherence [ 6 ].