The Pharmaceutical Journal
Vol 271 No 7277 p742-743
29 November 2003

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Letters to the Editor

Adrenal insufficiency

Sodium- not acetate-based glucocorticoid injections

From Ms D. Kenward and Ms K. White

For anyone with adrenal insufficiency an emergency injection of 100mg hydrocortisone sodium phosphate (or hydrocortisone sodium succinate) can save their life. It prevents low blood pressure from triggering permanent disability or death, which in an adrenal crisis can arise from stroke, respiratory arrest or other complications. The onset of hypovolaemic shock can be rapid; a delay of less than two hours in receiving emergency treatment can bring a patient close to death.

Because prompt emergency treatment is essential, many patients with steroid-dependent adrenal insufficiency are now issued with a personal injection kit. Liquid hydrocortisone sodium phosphate 100mg (Efcortesol) is the drug of choice for self-administration by steroid-dependent patients; hydrocortisone sodium succinate 100mg (Solu-Cortef) powder for reconstitution is also recommended.

Where these are not available, some other forms of injectable steroid may be substituted, most commonly dexamethasone sodium phosphate 5mg. But not all forms of injectable steroid are fast-acting enough for emergency use. Acetate-based injectable steroids are unsuitable, both because of their delayed absorption and because their microcrystalline structure makes them incompatible with intravenous use.

Regrettably, we have evidence that in a few cases hospital pharmacies have overlooked the distinction between sodium and acetate-based injectable steroids, and have issued hydrocortisone acetate to patients with adrenal insufficiency for emergency use.

We would like all pharmacists to exercise caution when filling prescriptions for injectable steroids, and to check in cases whether the drug is required for emergency use.

Where pharmacists are issuing hydrocortisone sodium succinate 100mg (Solu-Cortef), we suggest they should, in all cases, ensure the patient receives vials of water for reconstitution, which have a similar expiry date to their Solu-Cortef supply.

Deana Kenward
Katherine G. White
Addison’s Disease
Self-Help Group
www.adshg.org.uk

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