special situations

Last reviewed 01/2018

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