Steroid supplementation required for patients with primary adrenal insufficiency undergoing a dental procedure
Roshan Bains discusses what steroid supplementation is needed for patients with primary adrenal insufficiency.
Primary adrenal insufficiency (Addison’s disease) is a potentially fatal condition affecting the production of cortisol and aldosterone by the cortex of the adrenal gland. Cortisol is required for regulating extracellular fluid in the body, and a lack of it causes symptoms like fatigue, low blood sugar and nausea. Aldosterone regulates the balance of salt and water, which in turn maintains blood volume and pressure. Addison’s disease leaves patients dependant on life-long daily steroid medication and if deprived of this, patients will start to feel unwell within hours and their condition could turn fatal within days.
The corticosteroid replacement therapy usually prescribed is hydrocortisone (a glucocorticoid) and fludrocortisone (a mineralocorticoid). Prescribed hydrocortisone doses range from 20-30mg separated over two or three doses daily. Larger doses are usually taken in the morning and a smaller dose at lunchtime and/or early evening, this is done to mimic normal diurnal rhythm of cortisol secretion. Fifty-300micrograms of fludrocortisone is given once daily. In some cases prednisolone or dexamethasone may be used instead of hydrocortisone, a 5mg dose of prednisolone is roughly equivalent to 20mg of hydrocortisone.
Cortisol can also be released when acute stress is inflicted on a patient – this may be in the form of an invasive dental procedure. Healthy patients release their own cortisol during such procedures, glucocorticoids are not stored within the body and must therefore be synthesised by the patient during or after the episode of stress.
Exogenous steroids taken by the patients do have the potential to suppress normal adrenal gland function, and this has prompted the recommendation for additional glucocorticoid supplementation when carrying out ‘stressful’ medical or dental procedures. You may see literature refer to this as ‘steroid cover’ or ‘perioperative stress steroids’. A patient’s failure to have sufficient cortisol levels can result in circulatory collapse and hypotension characteristic of an Addisonian crisis.
Adrenal crisis – prevention and management
Things you can do to prevent Addisonian crisis occurring:
- Discuss the dental procedure and steroid cover with patients in detail before treatment, providing them with written advice is always useful
- Organise whether the patient or surgery will provide an emergency hydrocortisone kit
- Keep treatments in morning appointments, when steroid levels are higher
- Just before starting treatment, check the patient has taken the correct dose of steroids prior to treatment and ensure the emergency hydrocortisone kit is available
- If you are unsure about anything, get in contact with the patient’s endocrinology team prior to treatment.
How do we manage a suspected adrenal crisis?
- Arrange for the patient’s emergency admission to hospital as soon as possible!
- If conscious and signs of hypotension are present, place the patient in a supine position with legs elevated slightly. If no signs of hypotension, then the patient’s most comfortable position is recommended
- If unconscious, place patient in a supine position with legs raised
- Ensure the patient has hydrocortisone (intravenously or intramuscularly) and stabilise with an intravenous saline solution (if available). Then arrange transfer to hospital. Hydrocortisone sodium phosphate (Efcortesol) and Hydrocortisone sodium succinate (Solu-Cortef) are both licensed for treatment during an adrenal crisis
- Hydrocortisone dosages during adrenal crisis are age dependant. Infants below one will have 25mg, children aged one to five years require 50mg and children above six require 50-100mg (judge based on size/age of child). Adults require 100mg
- Emergency fludrocortisone is not required.
The ADSHG surgical guidelines can be used when determining exactly how much steroid cover is appropriate. Dental procedures are split into three categories depending on the stress associated with them.
1) Minor dental procedures
For example replacing fillings, scale and polish, minor procedures are at low risk of adrenal crisis and so pre-operative steroid cover is not usually recommended. That being said, some may be more sensitive to the demands of the procedure, it is important that you as a dentist are aware and know how to deal with this.
Post-operatively, extra doses of steroids are only required when hypo-adrenal symptoms are seen.
2) Minor dental surgery
For example tooth extraction, root canal treatment.
One hour before the procedure, double the hydrocortisone dose up to 20mg as a maximum (or any other equivalent glucocorticoid). It is also recommended to continue taking double dosages for 24 hours after the procedure. After this the patient may return to their normal dose.
A good template to use as guidance is below. It is important to remember that this is only guidance, patient’s requirements may differ and this should be assessed with your clinical judgement.
On the day of the procedure:
- Take morning dose as usual
- One hour before procedure, take a double dose of the patient’s next arranged dose that day (up to 20mg hydrocortisone as a maximum, or equivalent glucocorticoid)
- After the procedure, all other doses the patient is due to take that day are doubled (up to 20mg hydrocortisone as a maximum, or equivalent glucocorticoid)
- The next morning, double the morning dose (up to 20mg hydrocortisone as a maximum, or equivalent glucocorticoid). Continue to double the dose until 24 hours post procedure, then return to normal dosages.
3) Major dental surgery
For example tooth extractions under general anaesthetic.
These patients will be managed in secondary care. One hundred milligrams of hydrocortisone is given intramuscularly just before anaesthesia. After the surgery, the patient’s usual dose of steroids should be doubled for the next 24 hours.
Emergency patients – what do we do then?
In the event an Addison’s patient presents as an emergency with pain or dental swelling. Delaying treatment will only prolong stress and immediate treatment is required to establish drainage.
Establish the patient’s usual corticosteroid replacement routine, when they took their last dose and what it was (if the patient has experienced this before they may have already increased their dose).
In the event of an emergency extraction, a double dose (up to 20mg) should be taken ideally one hour before the procedure. We use one hour, as this is approximately the time taken for peak hydrocortisone blood concentrations to appear. If treatment is a simple incision or root canal under local anaesthetic, it is not recommended that any extra doses be taken.
What about secondary adrenal insufficiency patients?
Secondary adrenal insufficiency is the decreased function of the adrenal gland due to a lack of ACTH – symptoms are similar to those of Addison’s. When treating these patients, the ADSHG surgical guidance can be used as they would if they were treating an Addison’s patient.
Steroid cover – helping or overloading our patients?
Since the mid-1950s the medical community has generally accepted the use of steroid cover when undergoing ‘stressful’ procedures. However, some authors (such as Nicholson, Burrin and Hall who wrote the paper ‘Peri-operative steroid supplementation’) have come to a different conclusion – they argue there is no need for extra steroid cover provided that patients take all normal doses of their steroids around the time of treatment. There is a consensus amongst these authors that providing this extra cover gives no added benefit to our patients and we are just going overboard in topping them up with steroids that can lead to problems of their own.
It is evident that more research is required in this field, and as new evidence becomes available, we may see changes in the recommendations for perioperative steroid cover.