Guidelines : Adrenal insufficiency

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) agrees the following place in therapy for glucocorticoids in line with NG243 (Adrenal insufficiency: identification and management)

First choice glucocorticoid or 1st line BLUE (ON INITIATION).

Hydrocortisone immediate release TABLETS

• 10mg should be used first line for doses of 5mg and above

Hydrocortisone immediate release GRANULES (in a capsule for opening) 

• For use in infants & children on doses below 5mg

Hydrocortisone immediate release SOLUBLE TABLETS

• Restricted to patients on dose of 10mg AND unable to swallow solid dosage form

Transfer to primary care after initiation and stabilisation of treatment with a minimum of 1 months’ supply from the specialist endocrinology team

Hydrocortisone oral solution – RED traffic light status

• For use in infants and children where smaller doses may be required

Hydrocortisone Immediate release 5mg GRANULES (in a capule for opening) - NON FORMULARY

• 5mg granules (in a capsule for opening) are not a cost-effective treatment option 

Hydrocortisone Buccal Tables – NON-FORMULARY

• MHRA drug safety update December 2018 (see link to alert)

 ALTERNATIVE 1st Line BLUE (ON INITIATION)

Prednisolone tablets

•  if multiple daily doses are not appropriate

Prednisolone oral solution

• If difficulty swallowing tablets

Prednisolone soluble tablets

•  If difficulty swallowing tablets

Transfer to primary care after initiation and stabilisation of treatment with a minimum of 1 months’ supply from the specialist endocrinology team

Prednisolone Enteric Coated tablets – NON-FORMULARY 

2nd line BLUE (ON RECOMMENDATION) by the specialist endocrinology team

Hydrocortisone modified release tablets

Fludrocortisone tablets for mineralocorticoid replacement

• if needed (to normalise serum electrolytes and plasma renin, and reduce postural symptoms and salt craving)

Dosing of glucocorticoids during acute illness

It is important for people with adrenal insufficiency to increase their corticosteroid doses at times of illness in order to reduce the risk of adrenal crisis. As a guide, for any moderate intercurrent illness (such as illness with fever, requiring bedrest, or requiring antibiotics), they should double their usual doses of Hydrocortisone until recovered, or if on Prednisolone, they should increase to a minimum dose of 10 mg daily (or follow specific advice as recommended by their specialist).

In order to allow patients to promptly increase their corticosteroid dose at times of need, and to avoid any risk from unexpected supply shortages, patients should ideally retain 2 months reserve supply at all times and should be reminded to renew their prescription in good time.