1. For all patients with hypoadrenalism, medical staff should ensure there is a clinical alert on Trak, specifying:

This patient has hypoadrenalism and is at risk of adrenal (Addisonian) crisis if steroids are withheld or during intercurrent illness.  Patient will need an increased dose of steroids during intercurrent illness and parenteral steroids if unable to swallow. Contact endocrinology for advice if required.

2. GP’s will be asked by the health board to create a KIS, using the following information:

This patient is at risk of an adrenal (Addisonian) crisis during an intercurrent illness or if steroid treatment is suddenly stopped.

Please follow the following guidance for increasing steroid treatment during intercurrent illness: 

• Mild illness with no fever - no increase necessary.
• Flu or other infection with fever - double steroid dose for duration of illness and see GP in 48 hrs if not better.
• Vomiting (more than once) or diarrhoea or severe illness - take double dose of steroid immediately. Administer 100mg hydrocortisone IM if not kept down. Attend emergency department without delay. 

Going forward, it will be important for medical staff to check that a KIS has indeed been completed and if not a reminder should be sent with a copy of the wording. ‘New patients’ will need a request from secondary care to have the KIS created, with a copy of the wording above.

3. This KIS can be accessed by ambulance crews, NHS 24 and GP out-of-hours, but is not accessible by Scottish Ambulance Service call handlers. Therefore, the above information also needs to be sent by email to: dataadmin@nhs.net. This will create a clinical alert that can be seen by call handlers and dispatchers. The appropriate SAS form should be attached to the email and this should be pasted into Trak, so that it is clear to clinical staff in the future that this has been done.

4. The new Pituitary Foundation document on ‘sick day rules’ should be given to all patients with hypoadrenalism. Patients should also be advised to carry a ‘steroid card’ and wear a ‘MedicAlert’ tag or bracelet.

5. The table documenting the clinical scenarios should be discussed in detail with the patient and they should be invited to read this carefully at home.

6. Patients should be given a contact number for the on-call registrar for advice if they are unsure about steroid dosing during intercurrent illness. Out-of-hours, they should contact NHS 24.

7. All patients with hypoadrenalism, of whatever aetiology, should be offered parenteral hydrocortisone for emergency use.

8. Patients should be encouraged to bring a family member with them to the training session and to discuss the indications for this treatment with other close family members and, if appropriate, friends.

9. A follow-up visit/telephone contact should be offered after 2-3 weeks, to ensure correct understanding by the patient and that they have spoken to other family members.

10. It is clear that in an ‘adrenal crisis’, many patients and relatives do not give parenteral hydrocortisone, even though they have received appropriate education. One reason is that they are worried that they might be giving the treatment unnecessarily. Therefore, it is important that clinical staff highlight that harm comes from not giving parenteral hydrocortisone and that no harm will come to the patient if it is given when not strictly necessary.

11. Patients should be advised to attend an emergency department if they have needed to administer parenteral hydrocortisone. If they need an ambulance then they must inform the call handler that they are having an ‘Addisonian/adrenal crisis’. It is important to emphasise to patients that this is the form of words that should be used, to ensure correct understanding by the call handler.

12. If a patient phones the nursing team and/or the on-call registrar, the advice given should mirror that contained in the Pituitary Foundation Leaflet. If the patient has features of an adrenal crisis (weak, dizzy, nausea, faint, loss of consciousness), a clear instruction needs to be give to take the parenteral hydrocortisone immediately and to attend an emergency department immediately.

13. At every clinic appointment, the opportunity should be taken to remind the patient of the sick day rules, ensure they have a copy of the Pituitary Foundation Guidelines, ensure they have an ‘in date’ home injection kit, that they are clear when this should be used and that family members are also clear on the indications and injection technique.