Why should I give my Adrenal Insufficiency Patient an Emergency Injection Kit?

Provision of a hydrocortisone emergency injection kit is standard practice and is the advice given by the ADSHG Clinical Advisory Panel and Society for Endocrinology, for the prevention of an acute adrenal crisis. Please find below more information on why it is vital to equip and educate patients with a hydrocortisone emergency injection kit.

Why do people with adrenal insufficiency need an emergency injection kit?

Each year, typically 8% of people with Addison's disease experience adrenal crisis. This means they need extra steroid medication immediately, in the form of an emergency injection of intra-muscular hydrocortisone. This is a medical emergency and must be treated immediately.

If my patients live near a hospital surely they can get an injection via A&E or at an emergency doctor's surgery?

An adrenal crisis can happen anywhere. At work. Out shopping. On holiday. When exercising, particularly if the sport is in a remote location such as a hill walk. If an ambulance crew is delayed in arriving to help a patient, or the patient is unable to get to a medical facility for any other reason, an injection kit could save their life.

Read a patient personal experience story, when a nasty encouter with gastroenteritis meant they self adminstered their injection kit at home whilst waiting for the ambulance, saving their life.

How can we be sure the patient will know how to administer the injection safely?

Training can be provided by the patients Endocrine Nurse, or via direction to the ADSHG website where there are print out injection instruction leaflets available along with training videos on the ADSHG YouTube channel, demonstrated by an endocrine specialist nurse.

During COVID, individual hospitals moved their training sessions online, such as Liverpool University Hospital. The video they created is available to watch here, delivers education regarding management of steroid replacement during illness and they also demonstrate how to reconstitute and administer an emergency hydrocortisone injection, for use in the event of an adrenal crisis.

This follows the Clinical Guidance by Simpson et al (2020), quote below.

"Patients with established AI and their carers/family members should be educated about the risks of intercurrent illness, trained in (self) administration of 100 mg im hydrocortisone (efcortisol or solucortef) and told that if the vomiting and diarrhoeal illness persists they should attend their local hospital, as they will need parenteral hydrocortisone and intravenous fluids without delay. Patients and their relatives or carers can be taught how to self-inject by their endocrine clinical nurse specialist."

Source: Simpson H, Tomlinson J, Wass J, Dean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clin Med (Lond). 2020 Jul;20(4):371-378. DOI: 10.7861/clinmed.2019-0324 PMID: 32675141; PMCID: PMC7385786.
Further - the information on the Steroid Emergency card developed by the Society for Endocrinology (SfE), Royal College of Physicians (RCP) and NHS England and NHS Improvement (NHSE&I), takes patients and health teams straight to the Society for Endocrinology Adrenal Crisis page which has all the relevant guidance on how to manage an adrenal crisis, and patient information links. New medical guidance has been released alongside the card and National Patient Safety Alert.

For paediatric patients, print out guidelines and demonstration videos are available on the Great Ormond Street Website here. Patients should also be given a copy of the BSPED Paediatric Steroid Treatment Card for further guidance.

Clinical Guidance

Please find below further guidance and links to expert clinical guidance, regarding the provision of a hydrocortisone emergency injection kit for a person with Addison's disease and adrenal insufficiency, for the prevention of an acute adrenal crisis.

"Equip. Ensure that the patient is in possession of an ‘up-to-date hydrocortisone emergency self-injection kit’ and that the patient and a relative/partner/friend is confident in self-administration of the injection. Consider refreshing knowledge by talking through the procedure over the phone and providing links to training videos on ADSHG website and on Adrenals EU."

"Educate. Ensure that all patients (and their families/partners/carers) are educated in the use of ‘the sick day rules’, that is, the need to increase their usual glucocorticoid replacement dose during intercurrent illness and the need to self-inject hydrocortisone and call for emergency medical assistance when the oral medication cannot be reliably absorbed due to vomiting or diarrhoea and/or the presence of severe and major illness or trauma."

Reference: Arlt, W., Baldeweg, S. E., Pearce, S. H. S., & Simpson, H. L. (2020). ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of adrenal insufficiency, European Journal of Endocrinology, 183(1), G25-G32.

"In patients with AI, adrenal crisis (AC) continues to lead to unnecessary deaths. We illustrate how University Hospitals Birmingham NHS Foundation Trust used the 4E framework (Engage, Educate, Equip and Empower) as a strategy in implementing the National Patient Safety Alert on steroid emergency card (SEC) to support the prevention, early recognition and management of AC in adults....Patients were equipped with SEC, hydrocortisone injection kit as well as means of accessing expert support and advice through our helpline."

Reference: Sherwin Criseno - The 4E (Engage, Educate, Equip and Empower): A framework for supporting the approach in the prevention, early recognition and effective management of adrenal crisis in adults. Endocrine Abstracts (2021) 77 P17 | DOI: 10.1530/endoabs.77.P17

"This geographic diversity highlights the need for Addison's patients to carry an emergency injection kit with them whenever they are away from home, and preferably to keep a spare set of injection materials in their car."

Reference: White K & Arlt W. Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. European Journal of Endocrinology 2010 162 115–120. (https://doi.org/10.1530/EJE-09-0559)

"In addition, every patient should have an emergency set (or two) consisting of 100 mg hydrocortisone for parenteral administration. This injectable hydrocortisone allows immediate action by an attending health-care professional. However, every patient should also be able to self-administer parenteral hydrocortisone and close relatives should also be trained."

Reference: Allolio B. Extensive expertise in endocrinology: adrenal crisis. European Journal of Endocrinology 2015 172 R115–R124. (https://doi.org/10.1530/EJE-14-0824)

Please share the ADSHG Emergency Injection Guide with your patients or consider providing training at your clinic, perhaps in the form of a hospital meeting where a group of people with adrenal insufficiency can learn and practise injection technique. Or why not create your own steroid education videos, like the Endocrine Specialist Nurses at the Royal Liverpool University Hospital.

Here are further online resources for patients

Where should patients obtain their kits from?

GP's or endocrinology teams can prescribe the items required for the kit and administration i.e. needles, sharp box etc. Inform pharmacies dispensing the items that patients have been trained in the use of needles and syringes so that they aren't unnecessarily withheld.

The ADSHG sells kit boxes, conveniently sized leaflets, amp snaps and vanishpoint syringes if patients prefer.

View our range of emergency kit accessories and other items to support patients in emergencies.

Share the ADSHG's advice on preparing their own emergency kit with your patients.

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