Question: What changes should be made to replacement medications during illness?

Answer: For minor febrile illnesses, like the flu or other viral illness, use the “three for three” rule. This can be done without notifying your endocrinologist. Increase your dosage to three times the maintenance dosage for three days, while doing all the other things you should do during such an illness (plenty of fluids, rest, and medications such as ibuprofen or aspirin to make you more comfortable). If your illness continues to worsen during those three days, or if you do not feel well enough to return to the maintenance dosage on the fourth day, call your physician. You would do the same thing if you were not taking glucocorticoid replacement. Your physician can decide if you should be seen in the office or if you can wait for another day or two and continue to take the extra steroid. Your physician may be aware that the current “bug” going around might last six or seven days.

For major illnesses, such as broken bones, automobile injury, or loss of major amounts of blood, or if you are vomiting and cannot take your oral medication, you should inject yourself with 4 mg of dexamethasone anywhere on your body, using the medication and a syringe that you have with you at all times. In case you are unconscious or cannot inject yourself, you should always have 1) a MedicAlert bracelet that indicates you have adrenal insufficiency, 2) a Medical Information Card in your wallet or purse that indicates what medications you are taking and what physician to call in an emergency, and 3) dexamethasone and a syringe on your person or in your purse that a paramedic or passerby can inject. You cannot harm yourself by injecting the dexamethasone. If you think you need to inject it, do so, and then get to a physician as soon as possible.

Finally, for major surgery, notify the surgeon that you have adrenal insufficiency so that supplemental glucocorticoid can be administered on the day of the procedure. Some surgeries, such as having all your wisdom teeth removed at the same time, fall into a grey area as to whether additional glucocorticoids are needed. If in doubt, it is safer to get steroid, than not. You should be back at your usual maintenance dosage with a day or two, and it will have caused no harm.

By Dr. James Findling MD (Winter, 2012)