The normal adrenal cortex responds to severe stress by secreting more than 300 mg/day of Cortisol. Intercurrent illness is stress and treatment is urgent, particularly of infections; the dose of corticosteroid should be doubled during the illness and gradually reduced as the patient improves. Effective chemotherapy of bacterial infections is specially important.
Viral infections contracted during steroid therapy can be overwhelming because the immune response of the body may be largely suppressed. This is particularly relevant to immunosuppressed patients exposed to varicella/herpes zoster virus, which may cause fulminant illness; they may need passive protection with varicella/zoster immunoglobulin, VZIG, as soon as practicable. Continuous use of prednisolone 20 mg/day (or the equivalent) is immunosuppressive. But a corticosteroid may sometimes be useful in therapy after the disease has begun (thyroiditis, encephalitis) and there has been time for the immune response to occur. It then acts by suppressing unwanted effects of immune responses and excessive inflammatory reaction. Vomiting requires parenteral administration. In the event of surgery being added to that of adrenal steroid therapy the patient should receive hydrocortisone 100-200 mg i.m. or i.v. with premedication. If there is any sign suggestive that the patient may collapse, e.g. hypotension, during the operation, i.v. hydrocortisone (100 mg) should be infused at once. Otherwise, if there are no complications, the dose is repeated 6-hourly for 24-72 h and then reduced by half every 24 h until normal dose level is reached.
Minor operations, e.g. dental extraction, may be covered by hydrocortisone 20 mg orally 2-4 h before operation and the same dose afterwards.
In all these situations an i.v. infusion should be available for immediate use in case the above is not enough. These precautions should be used in patients who have received substantial treatment with corticosteroid within the past year, because their hypothalamic/pituitary/adrenal system, though sufficient for ordinary life, may fail to respond adequately to severe stress. If steroid therapy has been very prolonged, these precautions should be taken for as long as 2 years after stopping it. This will mean that some unnecessary treatment is given, but collapse due to acute adrenal insufficiency can be fatal and the ill-effects of shortlived increased dosage of steroid are less grave, being confined to possible increased incidence and severity of infection.
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