Wednesday, November 3, 2010

Are Guidelines for Glucocorticoid Coverage in Adrenal Insufficiency Currently Followed?

Coralie Leblicq, MD, Diane Rottembourg, MD, Johnny Deladoëy, MD, PhD, Guy Van Vliet, MD, Cheri Deal, PhD, MD Corresponding Author

Received 11 January 2010; received in revised form 14 July 2010; accepted 17 August 2010. published online 01 November 2010.

 

Objectives

To search for evidence of acute adrenal failure linked to inappropriate use of stress management protocols.


Study design

Patients followed up for primary adrenal insufficiency (n = 102) or secondary adrenal insufficiency (n = 34) between 1973 and 2007 were included. All hospitalizations, both urgent (n = 157) and elective (n = 90), were examined. We recorded clinical evidence of acute adrenal failure, parental management before admission, and details of glucocorticoid prescription and administration in the hospital setting.


Results

For urgent hospitalizations, subgroup and time period did not influence the percentage of patients hospitalized (primary adrenal insufficiency 45%; secondary adrenal insufficiency 38%; P = .55). The use of stress glucocorticoid doses by parents increased significantly after 1997 (P < .05), although still only 47% increased glucocorticoids before hospitalization. Stress doses were more frequently administered on arrival in our emergency department after 1990 (P < .05); patients with signs or symptoms of acute adrenal failure decreased to 27% after 1997 (P < .01). Twenty-four percent of all hospitalizations were marked by suboptimal adherence to glucocorticoid stress protocols, with rare but significant clinical consequences.


Conclusions

In spite of an increased use of glucocorticoid stress dose protocols by parents and physicians, patients remain at risk of morbidity and death from acute adrenal failure. This risk may be minimized with conscientious application of stress protocols, but other patient-specific risk factors may also be implicated.

 

Keywords

21OH, 21-hydroxylase, 3?HSD, 3-?-hydroxysteroid dehydrogenase, ACTH, Adrenocorticotropic hormone, AI, Adrenal insufficiency, CAH, Congenital adrenal hyperplasia, ED, Emergency department, EH, Elective hospitalization, HPA, Hypothalamic-pituitary-adrenal, PAI, Primary adrenal insufficiency, UH, Urgent hospitalization

 

Endocrinology Service and Research Center, CHU Sainte-Justine and Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada

Corresponding Author InformationReprint requests: Cheri Deal, PhD, MD, FRCPC, Endocrinology Service, CHU Sainte-Justine Hospital, Research Center, 3175 Côte Sainte-Catherine, Montréal (Québec), Canada, H3T 1C5.

Supported by scholarships from the Belgian Study Group of Pediatric Endocrinology (C.L.), the Fonds de Recherche en Santé du Québec (C.D.), and a donation from Group Cossette Communications (C.D.). The authors declare no conflicts of interest.

PII: S0022-3476(10)00690-6

doi:10.1016/j.jpeds.2010.08.021

 

From http://www.jpeds.com/article/PIIS0022347610006906/abstract?rss=yes