Daily Adjustment of Glucocorticoids by Patients With Adrenal Insufficiency

Christof Schöfl; Bernhard Mayr; Nicole Maison; Felix Beuschlein; Gesine Meyer; Klaus Badenhoop; Tina Kienitz; Marcus Quinkler


Clin Endocrinol. 2019;91(2):256-262. 

In This Article


Analysis of diaries of 80 AI patients resulted in 34 074 documented days (93.4 years; median 356 days per patient; 10%-90% percentile 172–767 days per patient). In this period, 4622 days with discomfort (13.6% of all days) were recorded. While 9 patients (4 women and 5 men) recorded not a single day of discomfort, 71 experienced at least one day of discomfort. On 35% of days with discomfort (n = 1621), patients performed a dose adjustment of their daily GC dose (4.8% of all days). After excluding days with prophylactic dose adjustment and dose adjustment advised or administered by a physician, 1477 days remained with discomfort and dose adjustment performed by patients (4.3% of all days).

During the documented time period, 486 episodes with discomfort occurred in which the patients increased their dose (median: 4 episodes per patient; 10%-90% percentile: 1–9 episodes). The episodes lasted between 1 and 44 days, and the median was 2 days (10%-90% percentile: 1–4 days). There were no differences between patients with primary (PAI) or secondary AI (SAI) regarding the number of episodes of discomfort or the duration of these episodes. However, women documented significantly more episodes of discomfort than men (P = 0.014; median 5.5 vs 3.0; 10%-90% percentile 1.1-23.9 vs 1.0-11.0), but the duration of episodes was not different. We did not observe any differences in number and duration of episodes with discomfort between patients on hydrocortisone or on prednisolone. However, the number of patients on prednisolone was rather small (n = 12). We could not identify any correlations between the number and duration of episodes with discomfort and hydrocortisone equivalent dose (mg/d), daily fludrocortisone dose, age or duration of AI.

During episodes with discomfort and dose adjustment, patients increased their median GC dose by 50% (median; 10%-90% percentile: 25% to doubling the dose) when they had a sign and symptom score (ssScore) of 1–3. They further increased their median GC dose by 60% (median; 10%-90% percentile: 25% to doubling the dose) when they had a ssScore of 4–6. Finally, a symptom score of 7 and 8 or presence of fever resulted in doubling the median GC dose (Figure 1). However, the increase in GC dose during symptoms which might indicate a GI infection was only 55% (median; 10%-90% percentile: 30% to doubling the dose; Figure 1). Furthermore, it is noteworthy that several patients doubled or tripled their daily dose even with a low symptom score present (Figure 1).

Figure 1.

Mean glucocorticoid (GC) dose increase in patients with adrenal insufficiency (AI) during phases of discomfort and illness. Scores (1–8) were calculated using the sign and symptoms score sheet shown in Table 2. Black bars show median. 100% = normal daily GC dose; 200% = double of daily GC dose; 300% = tripling of the daily GC dose. GI, gastrointestinal

There were two documented episodes of AC (2.1/100 patient years). One was triggered by pneumonia during a hospital stay for orthopaedic surgery and a second one prompted by viral infection of the upper respiratory tract with documented hyponatraemia which required hospitalization and iv hydrocortisone. In both cases, therapy was adjusted by physicians and these events were not included in the single day evaluation.