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In adrenal emergencies, high variability in management persists
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Adults with adrenal insufficiency who experience adrenal emergencies have widely varying wait times for lifesaving glucocorticoid administration, despite a nationwide effort to improve patient and provider education, according to findings from a prospective study conducted in Germany.
Despite established hormone therapies, the mortality in patients with chronic adrenal insufficiency is increased vs. the overall population, Stefanie Hahner, MD, an endocrinologist in the endocrine and diabetes unit at University Hospital of Würzburg, Germany, and colleagues wrote in the study background. A prospective study noted a frequency of about eight adrenal crises per 100 patient-years and an adrenal crisis-associated mortality frequency of 0.5 per 100 patient-years for those with adrenal insufficiency.
“The current study for the first time assessed emergency management within [adrenal insufficiency] in a prospective setting, showing large variability in emergency management,” the researchers wrote. “The median time from showing the emergency card to a medical professional to parenteral [glucocorticoid] administration by a medical professional (card-injection time) was 60 minutes, and only 45% of the patients received [glucocorticoid] by a physician within 30 minutes, a time interval recently recommended by experts in the field.”
Hehner and colleagues analyzed survey and medical records data from 150 patients with documented chronic adrenal insufficiency under established corticosteroid replacement therapy from University Hospital Wuerzburg, University Hospital Frankfurt and an endocrinology practice in Berlin (114 women; mean age, 52 years; median duration of adrenal insufficiency, 12 years). Within the cohort, 104 patients had primary adrenal insufficiency, 41 patients had secondary adrenal insufficiency and five patients had iatrogenic adrenal insufficiency, with 71% having participated in a Germany-wide standardized education program for patients with adrenal insufficiency.
Patients completed a questionnaire assessing the management of adrenal emergencies by patients or relatives and the consulted medical professional. Researchers evaluated symptoms, onset, causes of acute health deterioration, method and amount of glucocorticoid administered, hospitalization and duration of hospital stay. Researchers also assessed the time interval between arrival of a medical professional and parenteral glucocorticoid administration and the time interval between glucocorticoid administration and improvement of symptoms.
During 191 patient-years, researchers observed 59 adrenal emergencies leading to parenteral glucocorticoid administration in 39 patients. Of those, 55.9% received glucocorticoid administration by a hospital physician, 32.2% by self-injection, 15.3% from injection by a relative, 11.9% by an emergency physician and 6.8% by a family physician. The mean time of arrival of a medical professional and showing the emergency card to parenteral glucocorticoid administration by a physician (card-injection time) was 60 minutes, according to researchers, with 10 of the 43 patients receiving glucocorticoid from a medical professional already performing a self-injection before receiving the IV injection. In cases of previous self-injection, the mean card-injection time was 25 minutes.
Researchers found that the time from the beginning of symptoms to glucocorticoid injection was shorter in cases of self-injection vs. administration by a medical professional (mean, 85 minutes vs. 232.5 minutes; P < .001). After self-injection, 62% of the patients were treated in outpatient settings vs. 27% of patients treated in outpatient settings after exclusive injection by a medical professional (P = .008).
The researchers noted that only 17% of patients said they believed that the management of adrenal emergencies proceeded optimally, with 84% indicating that the handling of self-injection of glucocorticoid therapy should be simplified.
“Patients felt overchallenged by the complexity of the actions that need to be taken for preparation of the [glucocorticoid] injection under conditions of impaired general health condition,” the researchers wrote, adding that “34% of the patients believed that the emergency management by medical professionals should be improved, since delays occurred in parenteral [glucocorticoid] injection despite presentation of the emergency card.”
The researchers noted that findings confirm the high variability of emergency management in patients with adrenal insufficiency, despite the introduction of standardized patient education.
“Within this context, self-injection is obviously a helpful tool and a simplification of treatment is clearly needed,” the researchers wrote. – by Regina Schaffer
Disclosures: The authors report no relevant financial disclosures.
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