Centre for Endocrinology,

Diabetes and Metabolism

Endocrinology in the time of COVID-19

Management of Adrenal Insufficiency

Wiebke Arlt

Adrenal Insufficiency – Who is affected?

Glucocorticoid Regulation:

The Hypothalamic-Pituitary-

Adrenal (HPA) Axis

Addison’s Disease

1:10,000

Hypopituitarism

3:10,000

Congenital Adrenal Hyperplasia (CAH)

1:12,000

PRIMARY AI

SECONDARY AI

SECONDARY AI

AI and COVID-19

Increased probability of an inpatient

admission with infection for AI

cohorts

Exploring Inpatient Hospitalizations and

Morbidity in Patients With Adrenal Insufficiency.

Stewart PM, Biller BM, Marelli C, Gunnarsson C,

Ryan MP, Johannsson G.

J Clin Endocrinol

Metab. 2016 Dec;101(12):4843-4850.

PAI

SAI

Adrenal Insufficiency – Increased Risk from COVID-19

Increased Infection Risk

in Addison's Disease and

Congenital Adrenal Hyperplasia.

Tresoldi AS, Sumilo D, Perrins M,

Toulis KA, Prete A, Reddy N,

Wass JAH, Arlt W,

Nirantharakumar K.

J Clin Endocrinol Metab. 2020

Feb 1;105(2). pii: dgz006. Free

PMC Article

Addison’s

CAH

Adrenal Insufficiency – Risk of Adrenal Crisis

Primary adrenal insufficiency is associated with impaired natural killer cell function: a potential link to

increased mortality. Bancos I, Hazeldine J, Chortis V, Hampson P, Taylor AE, Lord JM, Arlt W.

Eur J Endocrinol. 2017 Apr;176(4):471-480. Free PMC Article

Patients with AI have reduced natural

killer cell cytoxicity

Deficient innate immunity defense

against virus infection

AI and COVID-19

Increased Risk to catch COVID-19 in patients with AI:

• Increased risk of infection including risk of respiratory infections and viral infections

• No evidence at present that COVID-19 has a more severe course in AI

Increased Risk from COVID-19 in patients with AI:

• Patients with AI experiencing major inflammation and fever are at risk of life-threatening adrenal crisis

Endocrinology in the time of COVID-19: Management of adrenal insufficiency.

Arlt W, Baldeweg SE, Pearce SHS, Simpson HL.

Eur J Endocrinol. 2020 Apr 1. pii: EJE-20-0361. doi: 10.1530/EJE-20-0361. [Epub ahead of print]

AI and COVID-19

Endocrinology in the time of COVID-19: Management of adrenal insufficiency.

Arlt W, Baldeweg SE, Pearce SHS, Simpson HL.

Eur J Endocrinol. 2020 Apr 1. pii: EJE-20-0361. doi: 10.1530/EJE-20-0361. [Epub ahead of print]

Educate• General Sick Day Rules, Special COVID-19 Sick Day Rules• Observe stringent social distancing

Equip• Provide with sufficient hydrocortisone supplies• Up-to-date hydrocortisone emergency self-injection kit

Empower• Provide with Hydrocortisone Steroid Emergency Card

• Steroid emergency card

AI and COVID-19

https://www.endocrinology.org/adrenal-crisis

• Steroid emergency card

• Prescribe Hydrocortisone Emergency Self Injection Kit and train patient & partner in its use

AI and COVID-19

• Provide patient with emergency telephone number

AI Sick Day Rules

Normal glucocorticoid replacement doses

Hydrocortisone 15-10-0mgHydrocortisone 10-5-5mg

“Sick Day Rules”Double the dose:

Hydrocortisone 30-20-0mgHydrocortisone 20-20-10mg

AI and COVID-19

Fever and Inflammation highly increase cortisol output by the healthy adrenal

=> Increased glucocorticoid dose requirements in patients with AI experiencing high fever

Mapping the Steroid Response to Major Trauma From Injury to Recovery: A Prospective Cohort Study.

Foster MA, Taylor AE, Hill NE, Bentley C, Bishop J, Gilligan LC, Shaheen F, Bion JF, Fallowfield JL,

Woods DR, Bancos I, Midwinter MM, Lord JM, Arlt W.

J Clin Endocrinol Metab. 2020 Mar 1;105(3). pii: dgz302. Free PMC Article

Normal AI Sick Day Rules

COVID-19 AI Sick Day Rules

Continuous Fever, as in COVID-19, requires continuous glucocorticoid replacement

AI and COVID-19

Endocrinology in the time of COVID-19: Management of adrenal insufficiency.

Arlt W, Baldeweg SE, Pearce SHS, Simpson HL.

Eur J Endocrinol. 2020 Apr 1. pii: EJE-20-0361. doi: 10.1530/EJE-20-0361. [Epub ahead of print]

AI and COVID-19

Endocrinology in the time of COVID-19: Management of adrenal insufficiency.

Arlt W, Baldeweg SE, Pearce SHS, Simpson HL.

Eur J Endocrinol. 2020 Apr 1. pii: EJE-20-0361. doi: 10.1530/EJE-20-0361. [Epub ahead of print]

Onset of signs and symptoms suggestive of COVID-19 (fever >38°C (>100 F), a new or continuous dry cough, sore throat, loss of sense of smell or taste, aches and pains, fatigue)

20 mg hydrocortisone orally every 6 hours Patients on modified release hydrocortisone should switch to immediate release hydrocortisone and take 20 mg

orally every 6 hours

Patients on 5-15 mg prednisolone daily should take 10 mg prednisolone every 12 hours; patients on oral

prednisolone >15 mg should continue their usual dose but take it split into two equal doses of at least 10 mg each.

Take paracetamol 1000 mg every 6 hours for fever

Rest, drink regularly throughout day and night and monitor whether passing urine

regularly

Request medical advice on the suspected COVID-19 infection

AI and COVID-19

Prevention of adrenal crisis: cortisol responses to major stress compared to stress dose hydrocortisone delivery.

Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O'Neil DM,

Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W.

J Clin Endocrinol Metab. 2020 Mar 14. pii: dgaa133.

Continuous intravenous infusion (CIV) of Hydrocortisone 200mg/24hpreferred in the Patient with AI & Major Stress

In AI & Major Stress 100mg i.v. hydrocortisone bolus injection Followed by 200mg hydrocortisone /24h per

continuous intravenous infusion

AI and COVID-19

Endocrinology in the time of COVID-19: Management of adrenal insufficiency.

Arlt W, Baldeweg SE, Pearce SHS, Simpson HL.

Eur J Endocrinol. 2020 Apr 1. pii: EJE-20-0361. doi: 10.1530/EJE-20-0361. [Epub ahead of print]

Onset of signs and symptoms of clinical deterioration (dizziness; intense thirst; shaking uncontrollably; drowsiness, confusion, lethargy; vomiting; severe diarrhoea; increasing shortness of breath, respiratory rate >24/min , difficulty speaking

Immediately inject (patient or carer) 100 mg hydrocortisone per i.m. injection

Call for emergency medical attention for treatment and transfer to hospital, consider

making their own way to hospital

Present steroid card to medical emergency staff

In Hospital: Inject 100mg hydrocortisone i.v., followed by continuous i.v. infusion of

200mg hydrocortisone (alternative 6-hourly 50mg hydrocortisone i.m. or i.v.

injections)

Centre for Endocrinology,

Diabetes and MetabolismAdrenal Team

• Wiebke Arlt• Miriam Asia• Sherwin Criseno• Yasir Elhassan• Chona Feliciano• Helena Gleeson• Alessandro Prete• Cristina Ronchi

Stephanie BaldewegSimon PearceHelen Simpson

David J. Smith