Perspective

AACE statement offers COVID-19 guidance for people with adrenal insufficiency, Cushing’s syndrome

Theodore C. Friedman
Theodore C. Friedman

People with adrenal insufficiency or uncontrolled Cushing’s syndrome are at greater risk for death from a respiratory-related infection, such as COVID-19, and should observe several key recommendations to avoid complications, according to a new position statement issued by the American Association of Clinical Endocrinologists.

“With the novel COVID-19 virus continuing to spread, it is crucial to adhere to the advice from experts and the Centers for Disease Control and Prevention to help reduce risk of infection for individuals and the population at large. This is particularly important for people with adrenal insufficiency and people with uncontrolled Cushing’s Syndrome,” AACE stated on its website. “Studies have reported that individuals with adrenal insufficiency have an increased rate of respiratory infection-related deaths, possibly due to impaired immune function.”

The statement noted that people with adrenal insufficiency should continue to take their medications as prescribed and ensure they have appropriate supplies for oral and injectable steroids at home, with a 90-day preparation recommended.

“In the case of hydrocortisone shortages, ask your pharmacist and physician about replacement with different strengths of hydrocortisone tablets that might be available,” the statement said.

However, when drug shortages are a concern, it is important for people to avoid panicking, according to Theodore C. Friedman, MD, PhD, chairman of the department of internal medicine and endowed professor of cardiometabolic medicine at Charles R. Drew University of Medicine and Science in Los Angeles.

“This idea of making sure you have an appropriate supply, people can read that and interpret that as they need extra,” Friedman told Healio. “I’m receiving a deluge of requests from people who want to stock up on their medicines. That is causing shortages, and it is not needed. What I recommend is use a mail order pharmacy for any medications. This situation is going to help move more people in that direction. Why go outside and stand in line, when you can get it delivered to your house and sign up for a 3-month supply with automatic refills, where you are guaranteed to receive your medications on time? Most insurance companies don’t allow people to get ‘extra’ medicine.”

When to ‘stress dose’

In the event of acute illness, those with adrenal insufficiency are instructed to increase their hydrocortisone dose per instructions and call their health care provider for more details. Standard “sick day” rules for increasing oral glucocorticoids or injectables would also apply, according to the statement.

Richard Auchus
Richard Auchus

“In general, patients should double their usual glucocorticoid dose in times of acute illness,” the statement said.

Richard Auchus, MD, PhD, professor of pharmacology and internal medicine in the division of metabolism, endocrinology and diabetes at the University of Michigan, said individuals with adrenal insufficiency should avoid so-called stress dosing if not acutely ill.

“If you get a head cold, some nasal congestion and you are eating and drinking normally, that is probably not coronavirus,” Auchus told Healio. “People with adrenal insufficiency should not stress dose if they are not sick. It will not prevent them from getting infected. If a person has a cough with shortness of breath and a fever, or perhaps with gastrointestinal symptoms, then that person should call his or her physician and start the stress dosing protocol according to their physician’s instructions. The number one most important thing is to prevent the infection in the first place and to do that by following the social isolation instructions. You don’t need to do any more or less than that, because everyone is doing the same thing.”

Auchus also cautioned that people with adrenal insufficiency should be prepared with emergency medications.

“Be prepared with your emergency hydrocortisone sodium succinate injection (Solu-Cortef, Pfizer) and small supplies of longer-acting glucocorticoids for the beginnings of symptoms, to allow for more time to take an injection and get to the ER for evaluation. Have your medical alert identification.”

Cushing’s syndrome, infection risk

Individuals with uncontrolled Cushing’s syndrome of any origin are at higher risk for infection in general, according to the statement.

“Although information on people with Cushing’s Syndrome and COVID-19 is scarce, given the rarity of the condition, those with Cushing’s syndrome should strictly adhere to CDC recommendations,” the statement said.

Recommendations include maintaining social distancing to reduce the risk for contracting COVID-19. People experiencing fever, cough or shortness of breath should call the COVID-19 hotline and their primary care provider or endocrinologist for further instructions.

The statement also recommended people with adrenal insufficiency use medical identification jewelry that clearly indicates on their emblem the need for urgent parenteral hydrocortisone in the event of an adrenal crisis. – by Regina Schaffer

Disclosure: Auchus reports he is a consultant for Quest Diagnostics.

Theodore C. Friedman
Theodore C. Friedman

People with adrenal insufficiency or uncontrolled Cushing’s syndrome are at greater risk for death from a respiratory-related infection, such as COVID-19, and should observe several key recommendations to avoid complications, according to a new position statement issued by the American Association of Clinical Endocrinologists.

“With the novel COVID-19 virus continuing to spread, it is crucial to adhere to the advice from experts and the Centers for Disease Control and Prevention to help reduce risk of infection for individuals and the population at large. This is particularly important for people with adrenal insufficiency and people with uncontrolled Cushing’s Syndrome,” AACE stated on its website. “Studies have reported that individuals with adrenal insufficiency have an increased rate of respiratory infection-related deaths, possibly due to impaired immune function.”

The statement noted that people with adrenal insufficiency should continue to take their medications as prescribed and ensure they have appropriate supplies for oral and injectable steroids at home, with a 90-day preparation recommended.

“In the case of hydrocortisone shortages, ask your pharmacist and physician about replacement with different strengths of hydrocortisone tablets that might be available,” the statement said.

However, when drug shortages are a concern, it is important for people to avoid panicking, according to Theodore C. Friedman, MD, PhD, chairman of the department of internal medicine and endowed professor of cardiometabolic medicine at Charles R. Drew University of Medicine and Science in Los Angeles.

“This idea of making sure you have an appropriate supply, people can read that and interpret that as they need extra,” Friedman told Healio. “I’m receiving a deluge of requests from people who want to stock up on their medicines. That is causing shortages, and it is not needed. What I recommend is use a mail order pharmacy for any medications. This situation is going to help move more people in that direction. Why go outside and stand in line, when you can get it delivered to your house and sign up for a 3-month supply with automatic refills, where you are guaranteed to receive your medications on time? Most insurance companies don’t allow people to get ‘extra’ medicine.”

When to ‘stress dose’

In the event of acute illness, those with adrenal insufficiency are instructed to increase their hydrocortisone dose per instructions and call their health care provider for more details. Standard “sick day” rules for increasing oral glucocorticoids or injectables would also apply, according to the statement.

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Richard Auchus
Richard Auchus

“In general, patients should double their usual glucocorticoid dose in times of acute illness,” the statement said.

Richard Auchus, MD, PhD, professor of pharmacology and internal medicine in the division of metabolism, endocrinology and diabetes at the University of Michigan, said individuals with adrenal insufficiency should avoid so-called stress dosing if not acutely ill.

“If you get a head cold, some nasal congestion and you are eating and drinking normally, that is probably not coronavirus,” Auchus told Healio. “People with adrenal insufficiency should not stress dose if they are not sick. It will not prevent them from getting infected. If a person has a cough with shortness of breath and a fever, or perhaps with gastrointestinal symptoms, then that person should call his or her physician and start the stress dosing protocol according to their physician’s instructions. The number one most important thing is to prevent the infection in the first place and to do that by following the social isolation instructions. You don’t need to do any more or less than that, because everyone is doing the same thing.”

Auchus also cautioned that people with adrenal insufficiency should be prepared with emergency medications.

“Be prepared with your emergency hydrocortisone sodium succinate injection (Solu-Cortef, Pfizer) and small supplies of longer-acting glucocorticoids for the beginnings of symptoms, to allow for more time to take an injection and get to the ER for evaluation. Have your medical alert identification.”

Cushing’s syndrome, infection risk

Individuals with uncontrolled Cushing’s syndrome of any origin are at higher risk for infection in general, according to the statement.

“Although information on people with Cushing’s Syndrome and COVID-19 is scarce, given the rarity of the condition, those with Cushing’s syndrome should strictly adhere to CDC recommendations,” the statement said.

Recommendations include maintaining social distancing to reduce the risk for contracting COVID-19. People experiencing fever, cough or shortness of breath should call the COVID-19 hotline and their primary care provider or endocrinologist for further instructions.

The statement also recommended people with adrenal insufficiency use medical identification jewelry that clearly indicates on their emblem the need for urgent parenteral hydrocortisone in the event of an adrenal crisis. – by Regina Schaffer

Disclosure: Auchus reports he is a consultant for Quest Diagnostics.

    Perspective
    James Findling

    James Findling

    It is important to remember that many people with adrenal insufficiency are not taking the same hydrocortisone dose they were 30 or 40 years ago. This is because we have learned that that high of a dose can further suppress the immune system. I have many patients taking 15 mg to 20 mg per day. When they are sick, I ask them to triple, not double, the dose of hydrocortisone, because they are taking less on a daily basis.

    Another important point to keep in mind — just this week, one of our nurses told me our patients were having a difficult time getting prescriptions filled for hydrocortisone, or that the only strength available is 10 mg. This is likely because people with adrenal insufficiency are nervous and they want more hydrocortisone on hand and are stocking up on prescriptions. As far as I know, there is no shortage of hydrocortisone. I can understand the concern, but people need to be reassured that the country is not running out of medications to treat the common illnesses that we take care of every day, and hydrocortisone is no exception.

    • James Findling, MD
    • Director of Community Endocrinology Services and Clinical Professor of Medicine
      Medical College of Wisconsin in Milwaukee

    Disclosures: Disclosure: Findling reports he has served as a consultant and investigator for Corcept Therapeutics and Novartis.

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