General medical or ward staff

Hydrocortisone dependant patients

As hospital ward staff or a general health care professional, you may come into contact with a patient who is dependent on hydrocortisone (HC). 

Hydrocortisone is taken as a replacement for the natural hormone where this is deficient, either because there is a failure of hydrocortisone production by the adrenal gland (Addison’s disease), or pituitary deficiency of ACTH (the hormone that stimulates the production of hydrocortisone by the adrenal gland). 
Replacement therapy is also required for people who have congenital adrenal hyperplasia, which is a birth defect. Hydrocortisone is available as tablets under the trade name Hydrocortisone, containing 10mg or 20mg. Prednisolone may be prescribed to individual patients instead of hydrocortisone and works in the same way as hydrocortisone. Prednisolone is available as tablets under the trade name Deltacortril® containing 2.5mg or 5mg or Prednisolone 1mg or 5mg. An injection containing 100mg Hydrocortisone is available for emergency situations for those on hydrocortisone or prednisolone. For children, there are lower dose emergency injections available.

How does a patient take replacement HC?

The usual dose for hydrocortisone is 15-20mg by mouth, split over two or three times daily, and depending on the individual's endocrinologist’s recommendations. For example: 10mg before getting out of bed in the morning, 5mg at mid-day and 5mg no later than 6pm. Hydrocortisone should ideally taken with water and is better absorbed if taken before food. The usual dose for prednisolone is 5-7mg by mouth, split over two times daily.

When would a patient need to take more hydrocortisone?

If the person becomes ill then the body would naturally increase the output of steroid from their adrenals. Therefore if the person is taking replacement steroid (hydrocortisone) it is essential, to mimic the natural response by increasing the patient's dose appropriately of hydrocortisone or prednisolone.

Hydrocortisone is a steroid produced by the adrenal gland. A good majority of people with pituitary disease have to take replacement hydrocortisone daily, as they don’t produce this naturally. Therefore, as they take replacements, they don’t have the natural surge of cortisol if they become acutely ill, are vomiting or have severe shock.

Peak Timings ImageIn the stressful situations, an emergency hydrocortisone injection is vital! (The patient might have their own emergency 100mg hydrocortisone injection with them). This injection may be needed to save the patient’s life. If this injection is delayed, the patient can become very ill, very quickly. Blood pressure drops and coma can occur.

Visit our Essential Free Publications section to download a copy of our Hydrocortisone Patient Advice leaflet. This has information about hydrocortisone including: when to increase a dose, travel, sick day rules and what to do in an emergency (including administering an emergency injection). 

Patients with Diabetes Insipidus

As ward staff or a general health care professional, you may during your career care for a patient/patients with the condition Diabetes Insipidus (DI). It is important that you know what this condition is and also that you understand the importance of the medication which some DI patients take to manage their condition.

Diabetes Insipidus (DI) is a disorder in which the kidneys are unable to retain water, caused by the lack of a water-retaining hormone produced by the pituitary gland. This results in the production of large amounts of urine and in turn, greatly increased thirst. The condition requires medication to manage it effectively. Without such medication (DDAVP or Desmopressin) the condition will cause patients to become dangerously dehydrated and in extreme situations can become fatal. Many medical professionals are not aware of the potential effects of missing medication for Diabetes Insipidus, especially health professionals working outside Endocrinology. Many patients require frequent and regular medication in order to keep them from serious and fast deterioration.

The condition is characterised by the passage of large volumes of urine (>3 litres/24hrs), and persistent thirst. It is distinguished from diabetes mellitus (sugar diabetes) by “insipid” urine, i.e. lacking taste, in contrast to the “sweet tasting” urine of diabetes mellitus. A common cause of DI is inadequate secretion of vasopressin, the antidiuretic hormone, from the posterior pituitary. However, some patients suffer from renal conditions in which the kidneys fail to respond correctly to vasopressin; this is nephrogenic DI.

Trauma, infection, granulomatous disease (e.g., sarcoidosis) or tumours in the region of the hypothalamus or pituitary may reduce vasopressin secretion. Pituitary surgery not infrequently causes DI which is usually transitory lasting a few hours or days; occasionally it may be permanent and be accompanied by loss of other pituitary hormones. Pituitary surgery also causes other forms of hypopituitarism which are covered elsewhere.

We request that you ensure your hospital has a procedure in place between departments, so that when a patient with a rare endocrine condition such as Diabetes Insipidus and/or is hydrocortisone dependant, is admitted, there is a protocol for communcation between departments and your Endocrinology team.

Presenting symptoms of Diabetes Insipidus
• Polyuria, in excess of 3 litres/24hrs in adults
• Thirst and polydipsia (excessive drinking)
• Tiredness, lethargy and reduced concentration (often the result of lack of sleep due to night-time visits to the toilet)

Investigations and diagnosis
The diagnosis is suggested by copious volumes of dilute urine with normal or slightly raised serum sodium. A water-deprivation test for up to 8 hours with measurements of serum sodium, blood and urine osmolalities and urine volume at 2 hour intervals followed by observation of urinary responses to desmopressin (DDAVP - an artificial vasopressin), can differentiate DI from other causes of polyuria (i.e., persistent excessive drinking or nephrogenic DI). An MRI scan of the pituitary region to include the hypothalamus and posterior pituitary is necessary.

Treatment of Diabetes Insipidus
Mild cases of DI (urine output 3-4 litres/24 hrs) can be managed by ingestion of water to quench thirst. Others require desmopressin (DDAVP) which can be given orally, intranasally or parenterally. It is essential to avoid chronic overdosage which will cause hyponatraemia (low serum concentration of sodium). 

Long-term management of DI
Because of the risk of hyponatraemia, occasional (1 - 3 monthly)
measurements of serum sodium are advised. Some recommend missing desmopressin treatment one day each week to avoid the development of hyponatraemia.

Questions patients with DI may ask

  • Why am I so thirsty? 

Lack of the normal vasopressin secretion means that the kidneys are unable to concentrate the urine. This results in a high sodium level in the blood which stimulates thirst.

  • Why do I have to visit the toilet so often? 

Lack of vasopressin reduces the kidney’s ability to concentrate the urine resulting in the production of large volumes of urine.

  • Why do I have headaches? 

This can happen after your DI is treated and it is important to balance the dose of desmopressin and the amount of fluid you drink so as not to retain too much water and develop hyponatraemia (low sodium).

  • Will I recover from DI? 

DI can be caused by surgical trauma or accident and may in some cases be transitory, but patients may require treatment for life.

  • Is it harmful to miss a dose of DDAVP? 

Generally speaking it is safer to miss a dose of DDAVP than to take an extra dose. You will simply notice that your thirst will be greater than normal, and you should drink more.