Predicting an adrenal crisis: can we do it?

Excerpt

Primary adrenal failure is a condition which should be readily treated with a normal quality of life: we have long been aware of the basic pathophysiology. We are able to essentially fabricate the deficient hormones, and we have sophisticated assays to assess replacement adequacy. Nevertheless, normalisation of the quality of life, avoidance of adrenal crises, and attainment of a normal mortality, appear to be difficult goals to achieve [1]. As clinicians, we weave between the Scylla of under-treatment with consequent fatigue and general ill-health, and the ever-present risk of adrenal crises, as opposed to the Charybdis of over-treatment and the metabolic syndrome. Indeed, even in a highly experienced unit with skilled staff and good patient training, the risk of adrenal crises seems to be ever present [2]. Such patient training includes warnings of ‘sick day’ rules, emergency injection packs, and in some cases specific patient training days or evenings. It is important to know that subcutaneous injection can be virtually as effective as the standard suggestion of intramuscular hydrocortisone [3], although it should still be emphasised that the advice to ‘double the oral dose’ during febrile illnesses has hardly any firm evidence base. Nevertheless, in spite of all this activity, adrenal crises and their consequent morbidity and indeed mortality remain stubbornly present concerns in our patients’ lives. …