Audit on Steroid Replacement in Confirmed or Suspected COVID-19 Patients With Adrenal Insufficiency or Adrenal Suppression in a District General Hospital

Abstract

Abstract Aim: In response to new updated guidance from Society For Endocrinology April 2020, this Audit was conduct to assess the adequacy of steroid replacement in confirmed or suspected COVID-19 patients with adrenal insufficiency or adrenal suppression admitted to Bedford District General Hospital. In steroid dependent patients (Addison’s disease, adrenal insufficiency, pituitary steroid insufficiency, use of long term steroids for other conditions - 5mg or more of prednisolone (or equivalent doses) daily for longer than 4 weeks) admitted to hospital very unwell with confirmed or suspected COVID recommendations is to start on Hydrocortisone 100 mg per IV injection followed by continuous IV infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or IM bolus injection). Method: Retrospect data collection on Patients admitted in May 2020 to Bedford Hospital with suspected or confirmed COVID 19 disease with adrenal insufficiency or on long term steroid use. Those patients should be started on Hydrocortisone 100 mg per IV injection followed by continuous IV infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or IM bolus injection). Results: In May 2020, 295 patients admitted under the medical team in Bedford Hospital with confirmed or suspected COVID-19. Only 12 patients met the inclusion criteria, one patient with a diagnosis of Addison disease and the remaining 11 patients on long term steroids. None of these patients were managed as per updated guidelines. 6 patients had less than the adequate dose, they were started on prednisolone 30-40mg. 4 patients dose of oral steroids was only doubled, 1 patient received the same dose of oral steroid and the only confirmed Addison had higher dose of hydrocortisone. Moreover, In June 2020, The RECOVERY Outcome trial results showed that Dexamethasone 6mg for 10 days reduces the death by one third in hospitalised patient with severe respiratory complications of COVID-19. Dexamethasone 6mg is 12 times the physiological required steroid dose, this is equivalent to 240mg hydrocortisone, which is adequate for steroid replacement in patients with adrenal insufficiency or suppression. Conclusion: In view of these results and the outcome of the RECOVERY Trial, Local trust guidelines updated, indicated that any patient with Adrenal insufficiency or suppression including those on long term steroids very unwell admitted to the hospital should receive Dexamethasone if requiring oxygen or Hydrocortisone if not requiring oxygen. Recommendation of changes included teaching sessions delivered to doctors, posters on updated guidelines distributed in major areas in hospital and trust guidelines updated on the intranet.