people undergoing strenuous physical exercise e.g. - marathon runners
- may require up to twice the amount of glucocorticoid and mineralcorticoid plus sufficient fluid
- if there is a risk of injury (e.g. - horse riding, skiing) a team mate must have the expertise to administer an emergency injection (1)
people doing shift work - dose schedule should be changed according to the work pattern
people with essential hypertension
- present in around 10% patients treated for Addison’s
- ACE inhibitors and calcium channel blockers are used to manage blood pressure (diuretics should be avoided)
- decrease in fludrocortisone dose may be required (with electrolytes monitoring)(1)
post diagnosis pregnancies
- hydrocortisone does not need to be increased in pregnancy except in latter trimesters if there is severe hyperemesis gravidarum and toxaemia hospital treatment may be required (2)
- during labour and vaginal birth –
- hydrocortisone 100 mg IM (just before anaesthesia) pre operatively
- the oral dose should be doubled for 24-48 hours after delivery and if the patient is well can return to normal dose
- for cesarean section
- hydrocortisone 100 mg IM (just before anaesthesia) pre operatively
- continued every 6 hours for 24-48 hours (or until eating and drinking normally) post operatively
- then double the oral dose for 24-48 hours and later return to normal dose (1)
major surgery e.g. - open heart surgery, major bowel surgery
- hydrocortisone 100 mg IM just before anaesthesia and continued every 6 hours post operatively until they are able to take food orally
- double the normal replacement is then given orally and reduced to maintenance over a few days (1)
- Fludrocortisone is not required with this regime of hydrocortisone..
minor operations e.g. – cataract surgery, hernia operations
- hydrocortisone 100 mg IM just before anaesthesia
- then double the oral dose for 24 hours and return to normal dose
other invasive procedures e.g. – endoscopy, gastroscopy
- a single dose of hydrocortisone 100 mg IM just before starting the procedure
- then double the oral dose for 24 hours post operatively and return to normal dose
minor procedures e.g. – skin mole removal with local anaesthetics
- post operative extra dose may be needed where hypoadrenal symptoms occur afterwards
major dental surgery e.g. – dental extraction under general anaesthesia
- hydrocortisone 100 mg IM just before anaesthesia
- then double the oral dose for 24 hours post operatively and return to normal dose
dental surgery e.g. – root canal work with local anaesthesia
- double the dose (upto 20 mg) one hour before surgery
- then double the oral dose for 24 hours post operatively and return to normal dose
minor dental procedures e.g. - replace filling
- post operative extra dose only where hypoadrenal symptoms occur afterwards (1)
Reference:
- (1) Wass, J., Howlett, T., Arlt, W. et al. Caring for the Addison's patient: information for GPs. Addison's Disease Self Help Group 2007
- (2) Wass, J., Howlett, T., Arlt, W. et al. Glucocorticoid medication requirements for surgery and dentistry. Addison's Disease Self Help Group 2005