Variability in counselling for adrenal insufficiency in COVID-19 and beyond: a survey of rheumatology practice.
Variability in counselling for adrenal insufficiency in COVID-19 and beyond: a survey of rheumatology practice.
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DOI：
10.1016/s2665-9913(20)30389-1
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发表时间：
2021-03
期刊：
影响因子：
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通讯作者：
Mackie SL
中科院分区：
文献类型：
--
作者：
Mehta P;Meeran K;Macphie E;Abbas A;Rippin J;Jeffery RC;Reddy V;Leandro MJ;Ciurtin C;Simpson HL;Mackie SL
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The COVID19 pandemic has presented challenges and uncertainty for patients and physicians. Corticosteroids are the most commonly prescribed pharmacotherapy in rheumatology. Longterm corticosteroids are pre scribed for many rheumatic diseases, including rheumatoid arthritis, giant cell arteritis, and polymyalgia rheu ma tica. 1 Diabetes, hypertension, and weight gain (all poor prog nostic factors for COVID19) are widely recog nised adverse events associated with longterm corticosteroid use; how ever, the high prevalence of glucocorticoidinduced adrenal suppression (eg, in 20 [48%] of 42 patients with rheumatoid arthritis receiv ing prednisolone at≥ 5 mg/day for at least 6 months2) is less well known. Patients with adrenal insufficiency should be informed regarding corticosteroid sick day rules, including the risk of lifethreatening adrenal crisis if corticosteroids are dis con tinued suddenly, or if there is insufficient stress dosing. 3 Prompt supplementary corticosteroids are required in the context of significant intercurrent infection, includ ing COVID19, major trauma, or surgery; and intra venous cortico steroids are needed if vomiting. 3 Despite the importance for patient safety, guidelines regard ing corticosteroid sick day rules for rheumatology patients are unclear and, consequently, there is variation in prac tice. Most clinicians double the corticosteroid dose, but this crude ruleofthumb can lead to undertreat ment or overtreatment. Clear information for patients is par ticularly important during the current COVID19 pan demic due to restricted or modified access to usual levels of health care—eg, delayed or virtual conversion of clinic appoint ments and difficulty accessing helplines. In September, 2020, WHO recom mended corticosteroids to reduce mortality in critically ill COVID19 patients. 4 How ever, worse outcomes were suggested in patients with COVID19 not requiring supplemental oxygen. Signi ficantly poorer outcomes were reported in patients receiv ing at least 10 mg/day prednisolone (n= 64) 5 for rheu matic disease, but to the best of our knowledge, there has been no evidence of adverse outcomes attributed to supplemental stress doses of corticosteroids in COVID19.Here we report the results of a survey evaluating cortico steroid sick day rule counselling, and highlight an edu ca tional need to prevent adrenal crisis. In March, 2020, the British Society for Rheumatology (BSR) issued shield ing guidance for patients receiving long term (> 4 weeks) corticosteroids, either as highdose monotherapy (> 20 mg/day) or lowdose (≥ 5 mg/day) pred nisolone com bined with another immu no sup pres sant. 6 The shielding guidance identified cate gories of patients as clinically vulnerable, who were advised to take extra precautions during the first peak of the pan demic in England. Some clinicians and patients elec ted to delay starting or increasing corticosteroids for inflammatory flares, due to perceived safety concerns and to avoid needing to shield. Anecdotally, we became aware of safety incidents (adrenal crises) after discontinu ation of long term corticosteroids or inadequate dose increments with concomitant COVID19 (unpublished). In April, 2020, the BSR updated their advice to reflect endo crinology consensus guidelines on prevention of adrenal crisis for COVID19. 7 These guidelines stated that hospitalised patients on longterm corticosteroids with COVID19 should receive intravenous corticosteroids; in the com munity, patients taking 5 mg to 20 mg prednisolone daily should take 10 mg prednisolone twice daily and patients taking more than 20 mg should continue their usual dose, but in divided doses. 7 The twicedaily prednisolone dose (to mimic …