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<meta name="citation_keywords" content="Adrenal Insufficiency">
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<meta name="citation_keywords" content="Adrenal Hyperplasia, Congenital">
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<meta name="citation_keywords" content="Addison Disease">
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<meta name="citation_keywords" content="Stress, Physiological">
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<meta name="citation_keywords" content="Adrenal Cortex Hormones">
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<meta name="citation_keywords" content="Glucocorticoids">
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<meta name="citation_keywords" content="Treatment Outcome">
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<meta name="citation_keywords" content="Hydrocortisone">
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<meta name="citation_keywords" content="Prednisolone">
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<meta name="citation_keywords" content="Dexamethasone">
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stroke-linecap="round" style="fill:#FFF" d="m320,350a153,153 0 1,0-2,2l170,170m-91-117 110,110-26,26-110-110"></path></svg></a><a id="jr-fip-done" class="wsprkl btn" title="Dismiss find">✘</a></nav><nav id="jr-fip-info-p"><a id="jr-fip-prev" class="wsprkl btn" title="Jump to previuos match">◀</a><button id="jr-fip-matches">no matches yet</button><a id="jr-fip-next" class="wsprkl btn" title="Jump to next match">▶</a></nav></nav></div><div id="jr-epub-interstitial" class="hidden"></div><div id="jr-content"><article data-type="main"><div class="main-content lit-style"><div class="fm-sec bkr_bottom_sep"><div class="bkr_thumb"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng243er10-lrg.png" alt="Cover of Pharmacological management of physiological stress" /></a></div><div class="bkr_bib"><h1 id="_NBK609020_"><span itemprop="name">Pharmacological management of physiological stress</span></h1><div class="subtitle">Adrenal insufficiency: identification and management</div><p><b>Evidence review J</b></p><p><i>NICE Guideline, No. 243</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2024 Aug</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-6472-7</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2024.</div></div><div class="bkr_clear"></div></div><div id="niceng243er10.s1"><h2 id="_niceng243er10_s1_">1. Pharmacological management at times of physiological stress</h2><div id="niceng243er10.s1.1"><h3>1.1. Review question</h3><p>What is the clinical and cost effectiveness of pharmacological treatments for managing periods of physiological stress in people with adrenal insufficiency including:
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<dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>a)</dt><dd><p class="no_top_margin">planned and emergency invasive procedures</p></dd></dl><dl class="bkr_refwrap"><dt>b)</dt><dd><p class="no_top_margin">pregnancy and intrapartum care</p></dd></dl><dl class="bkr_refwrap"><dt>c)</dt><dd><p class="no_top_margin">intercurrent illness and periods of physiological stress including minor (for example, colds) and major illnesses (for example, severe infection, cardiac events)?</p></dd></dl></dl></p><div id="niceng243er10.s1.1.1"><h4>1.1.1. Introduction</h4><p>In times of physiological stress, the body produces additional cortisol. Under such circumstances, cortisol improves the efficiency of the heart, maintains blood pressure, ensures an adequate supply of glucose for cells to use for energy, and helps reduce inflammation.</p><p>Individuals with adrenal insufficiency are unable to produce high amounts of cortisol to meet the requirements for normal functioning during physiological stress. A failure to increase glucocorticoid replacement in times of physiological stress may place individuals at risk of adrenal crisis or even death. The amount of additional glucocorticoid required is different depending on the type of stressor, whilst severe illnesses such as sepsis, patients being in the intensive care unit or undergoing surgery require parental hydrocortisone. Although it is known that additional glucocorticoid dosing is recommended during periods of increased physiological stress, there is significant variation in clinical practice.</p><p>This review considers the clinical- and cost-effectiveness of pharmacological treatments for people with adrenal insufficiency at times of physiological stress.</p></div><div id="niceng243er10.s1.1.2"><h4>1.1.2. Summary of the protocol</h4><p>For full details see the review protocol in <a href="#niceng243er10.appa">Appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab1"><a href="/books/NBK609020/table/niceng243er10.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img" rid-ob="figobniceng243er10tab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab1"><a href="/books/NBK609020/table/niceng243er10.tab1/?report=objectonly" target="object" rid-ob="figobniceng243er10tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of review question. </p></div></div></div><div id="niceng243er10.s1.1.3"><h4>1.1.3. Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng243er10.appa">appendix A</a>. A summary of the criteria for assessing guidelines using the AGREE II tool is included in <a href="#niceng243er10.appk">Appendix K</a> and a more detailed description of its application is included in the methods document.</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng243er10.s1.1.4"><h4>1.1.4. Effectiveness evidence</h4><div id="niceng243er10.s1.1.4.1"><h5>1.1.4.1. Included studies</h5><p>A search was conducted for randomised studies comparing the administration of additional doses or corticosteroids to no additional doses or placebo at times of physiological stress in patients with adrenal insufficiency. One RCT was included in the review (Glowniak 1997<a class="bibr" href="#niceng243er10.ref5" rid="niceng243er10.ref5"><sup>5</sup></a>) and is summarised in <a href="/books/NBK609020/table/niceng243er10.tab2/?report=objectonly" target="object" rid-ob="figobniceng243er10tab2">Table 2</a> below. Evidence from this study is summarised in the clinical evidence summary below (<a href="/books/NBK609020/table/niceng243er10.tab4/?report=objectonly" target="object" rid-ob="figobniceng243er10tab4">Table 4</a>).</p><p>Glowniak included 17 male patients who were on long-term corticosteroid therapy and who had secondary adrenal insufficiency as determined by results of cosyntropin testing. They were all undergoing major surgical procedures and were randomised to receive stress doses of corticosteroids or placebo.</p><p>The committee wished to look for additional evidence through searches for non-randomised studies. However, these did not identify any additional non-randomised studies for inclusion. The committee agreed that the management of physiological stress is one of their priority areas for this guideline and therefore, in the absence of any research evidence, wished to review existing guidance documents to inform their recommendations. For that reason, a further systematic review of the literature was carried out to identify adrenal insufficiency guidelines that include recommendations on pharmacological management at times of physiological stress.</p><p>Eight guidelines were identified and included in the review.</p><ul><li class="half_rhythm"><div>Two guidelines were for adults with any type of AI (primary, secondary or tertiary) (Arlt 2016<a class="bibr" href="#niceng243er10.ref2" rid="niceng243er10.ref2"><sup>2</sup></a> and Simpson 2020<a class="bibr" href="#niceng243er10.ref9" rid="niceng243er10.ref9"><sup>9</sup></a>)</div></li><li class="half_rhythm"><div>Two for adults and children with any type of AI (Araujo-Castro 2020<a class="bibr" href="#niceng243er10.ref1" rid="niceng243er10.ref1"><sup>1</sup></a>, Woodcock 2020<a class="bibr" href="#niceng243er10.ref11" rid="niceng243er10.ref11"><sup>11</sup></a>)</div></li><li class="half_rhythm"><div>Two were for adults and children with primary AI (Bornstein 2016<a class="bibr" href="#niceng243er10.ref4" rid="niceng243er10.ref4"><sup>4</sup></a> and Husebye 2014<a class="bibr" href="#niceng243er10.ref6" rid="niceng243er10.ref6"><sup>6</sup></a>)</div></li><li class="half_rhythm"><div>One was for children only with any type of AI (Mushtaq 2023<a class="bibr" href="#niceng243er10.ref7" rid="niceng243er10.ref7"><sup>7</sup></a>)</div></li><li class="half_rhythm"><div>One was for adults and children with primary AI due to 21-hydroxylase deficiency (Speiser 2018<a class="bibr" href="#niceng243er10.ref10" rid="niceng243er10.ref10"><sup>10</sup></a>).</div></li></ul><p>See the study selection flow chart in <a href="#niceng243er10.appc">Appendix C</a>, study evidence tables in <a href="#niceng243er10.appd">Appendix D</a>, forest plots in <a href="#niceng243er10.appe">Appendix E</a> and GRADE tables in <a href="#niceng243er10.appf">Appendix F</a>.</p></div><div id="niceng243er10.s1.1.4.2"><h5>1.1.4.2. Excluded studies</h5><p>See the excluded studies list in <a href="#niceng243er10.appj">Appendix J</a>.</p></div></div><div id="niceng243er10.s1.1.5"><h4>1.1.5. Summary of studies included in the effectiveness evidence</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab2"><a href="/books/NBK609020/table/niceng243er10.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img" rid-ob="figobniceng243er10tab2"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab2"><a href="/books/NBK609020/table/niceng243er10.tab2/?report=objectonly" target="object" rid-ob="figobniceng243er10tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of studies included in the evidence review. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab3"><a href="/books/NBK609020/table/niceng243er10.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img" rid-ob="figobniceng243er10tab3"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab3"><a href="/books/NBK609020/table/niceng243er10.tab3/?report=objectonly" target="object" rid-ob="figobniceng243er10tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Summary of guidelines included in the review. </p></div></div><p>See <a href="#niceng243er10.appd">Appendix D</a> for full evidence tables.</p></div><div id="niceng243er10.s1.1.6"><h4>1.1.6. Summary of the effectiveness evidence</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab4"><a href="/books/NBK609020/table/niceng243er10.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img" rid-ob="figobniceng243er10tab4"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab4"><a href="/books/NBK609020/table/niceng243er10.tab4/?report=objectonly" target="object" rid-ob="figobniceng243er10tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">Clinical evidence summary: glucocorticoids versus placebo. See Appendix F for full GRADE tables. </p></div></div></div><div id="niceng243er10.s1.1.7"><h4>1.1.7. Economic evidence</h4><div id="niceng243er10.s1.1.7.1"><h5>1.1.7.1. Included studies</h5><p>No health economic studies were included.</p></div><div id="niceng243er10.s1.1.7.2"><h5>1.1.7.2. Excluded studies</h5><p>No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.</p><p>See also the health economic study selection flow chart in <a href="#niceng243er10.appg">Appendix G</a>.</p></div></div><div id="niceng243er10.s1.1.8"><h4>1.1.8. Economic model</h4><p>This area was not prioritised for new cost-effectiveness analysis.</p></div><div id="niceng243er10.s1.1.9"><h4>1.1.9. Unit costs</h4><p>Relevant unit costs are provided below to aid consideration of cost effectiveness.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab5"><a href="/books/NBK609020/table/niceng243er10.tab5/?report=objectonly" target="object" title="Table 5" class="img_link icnblk_img" rid-ob="figobniceng243er10tab5"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab5"><a href="/books/NBK609020/table/niceng243er10.tab5/?report=objectonly" target="object" rid-ob="figobniceng243er10tab5">Table 5</a></h4><p class="float-caption no_bottom_margin">Unit costs for pharmacological interventions for physiological stress in children. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10tab6"><a href="/books/NBK609020/table/niceng243er10.tab6/?report=objectonly" target="object" title="Table 6" class="img_link icnblk_img" rid-ob="figobniceng243er10tab6"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.tab6"><a href="/books/NBK609020/table/niceng243er10.tab6/?report=objectonly" target="object" rid-ob="figobniceng243er10tab6">Table 6</a></h4><p class="float-caption no_bottom_margin">Unit costs for pharmacological interventions for physiological stress in adults. </p></div></div></div></div><div id="niceng243er10.s1.2"><h3>1.2. The committee’s discussion and interpretation of the evidence</h3><div id="niceng243er10.s1.2.1"><h4>1.2.1. The outcomes that matter most</h4><p>The committee considered all outcomes listed in the protocol to be critical and of equal importance in decision-making. These outcomes included mortality, Health-related Quality of Life, incidence of adrenal crisis, acute and long-term cumulative adverse events of drugs, admission to hospital or ITU and psychological morbidities such as incidence of stress or PTSD.</p><p>The only evidence found was on blood pressure during surgical procedures and up to 3 days after. These were reported separately as lowest systolic and lowest diastolic blood pressure and change in systolic and diastolic blood pressure. The study was in a small group of male patients with secondary adrenal insufficiency and therefore the committee did not think this was enough evidence to support recommendations. Further literature searches for non-randomised studies did not retrieve any additional evidence.</p><p>The committee considered pharmacological management of physiological stress a priority area where recommendations would be highly valuable to healthcare professionals. They were aware of the existence of several national and international guidelines and wished to consider them in this review to assess their quality and consolidate the recommendations across them. Therefore, an additional systematic review of the literature was conducted to identify published guidelines that include recommendations on the pharmacological management of adrenal insufficiency at times of physiological stress.</p></div><div id="niceng243er10.s1.2.2"><h4>1.2.2. The quality of the evidence</h4><p>The clinical evidence for all outcomes in the included RCT was graded very low. This was largely due to the very serious risk of bias arising from the randomisation process and very serious imprecision. The study was in a small group of people and there was very low certainty in the evidence it provided. Therefore, the committee did not consider these results in their decision making.</p><p>A further systematic review of the literature was conducted to identify adrenal insufficiency guidelines that include recommendations on pharmacological management at times of physiological stress. Eight guidelines were identified and included in this review. Five guidelines covered all types of AI (primary, secondary and tertiary). Two of those were specifically for adults although one included some recommendations for children, one was for children only and two were for adults and children. Two guidelines covered primary AI in both children and adults one of them was specific to primary AI due to 21-hydroxylase deficiency.</p><p>The included guidelines were assessed by 2 reviewers using the AGREE II tool. This instrument is intended for assessing the quality of systematically developed clinical practice guidelines, including assessments of methodological rigour, transparency, and applicability. Where information was lacking, authors were contacted to provide further clarification.</p><p>The included guidance documents scored between 39% and 100% for scope and purpose. The overall aim, specific health questions and population covered by the guidelines were generally well described but details such as the potential health impact of the guidelines were sometimes lacking or limited.</p><p>The guidance documents scored between 0% and 100% for stakeholder involvement. Generally, they were not assessed as having been developed by a broadly representative group of relevant professionals and did not report that the views of intended users (practitioners, patients and their families) were represented. Correspondence with authors revealed that some guidelines had sought the views of patient organisations. Only one of the guidelines (BSPED) clearly stated that there was stakeholder involvement which included various professional and patient organisations.</p><p>Scores for rigour of development were low, ranging from 0% to 40%. Details on whether a systematic process had been used to search for and synthesise evidence, were not clearly described. The committee acknowledged that this is to be expected as research on adrenal crisis is difficult to conduct and very limited. Therefore, guideline authors may not see the need for conducting systematic searches of the evidence and may directly resort to expert opinion. However, this should not preclude authors from explaining the methods used to formulate the recommendations and how final decisions were arrived at (e.g., informal consensus or formal consensus techniques such as Delphi).</p><p>The included guidance documents scored between 56% and 100% for clarity of presentation. Recommendations were well presented, and key recommendations were clearly identifiable. However, some guidelines were lacking in clarity regarding different management options and therefore scored lower in this domain.</p><p>Scores for applicability were very low and ranged between 0% and 25%. There was a lack of advice on how the recommendations could be put into practice, and potential resource implications and no monitoring or auditing criteria were suggested. It was also unclear whether the likely barriers and facilitators to implementation and strategies to improve uptake of the guidance were considered.</p><p>The included guidance documents scored between 0% and 100% for editorial independence. Declaration of any bias or competing interests from guidance development group members and statement on whether the views of the funding bodies had influenced the content of the guidelines were not always clearly reported. One guideline did not include any declarations and others did so with varying degrees leading to a lack of transparency in editorial independence.</p><p>Once the assessment of the 6 domains (23 items) is completed, the AGREE II tool suggests two overall assessments. One is a rating of the overall quality of the guideline and the other asks whether the guideline would be recommended for use in practice. However, the review of external guidelines was not intended to recommend a particular guideline but to obtain an overview of the recommendations in national and international guidelines to inform the committee’s recommendations or to cross-refer to specific recommendations if they would add efficiencies to the guideline development process and add value to NICE guidance. The committee also acknowledged that whilst rigour of development would normally be considered a high priority in evaluating guidelines, they were aware of the difficulty in producing evidence-based guidelines for AI due to the limited research in this area. Their experience from conducting this systematic review had also proved that. They acknowledged that, knowing that there is limited evidence, most guideline authors do not conduct any literature searches and make recommendations solely on consensus. This inevitably leads to all the guidelines scoring low for rigour of development as they lack any details for assessing the rigour of their systematic reviewing process. Therefore, the committee agreed that prioritising specific domains that would help their decision-making would be more informative than assessing the guidelines based on an overall score. The committee agreed, that in the absence of evidence, a high-quality guideline should include a wide range of experience and expert opinion that represents the views of the intended users including patient representatives. The guideline should include a clear description of the methods by which opinions were sought and incorporated and final recommendations were reached (e.g. informal consensus, Delphi).</p><p>In addition, for the committee to consider cross referring to external guideline recommendations, they should be applicable to a UK setting. Therefore, the committee agreed that stakeholder involvement, particularly patient representation, and suitability to UK settings should be given strong consideration when assessing the quality of the guidelines as they will be more informative than an overall score.</p><div id="niceng243er10.s1.2.2.1"><h5>Adults</h5><p>Although the majority of the guidelines scored low for stakeholder involvement, the committee agreed that the recommendations were applicable to UK settings and were generally in agreement on how to manage pharmacological treatment at times of physiological stress. They were also in line with the committee’s expertise and current practice. Therefore, the committee wished to make their own consensus recommendations, informed by these guidelines. The committee found that the Woodcock guideline<a class="bibr" href="#niceng243er10.ref11" rid="niceng243er10.ref11"><sup>11</sup></a> which included recommendations from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK included the most comprehensive and clear recommendations on pharmacological management in the perioperative period. The guideline had scored 67% for stakeholder involvement and was directly applicable to UK settings. The committee wished to cross refer to some of the recommendations in the guideline if it was deemed to be of high enough quality. Therefore, the guideline recommendations were further assessed using the NICE second stage assessment process for evaluating the applicability and acceptability of recommendations from external guideline developers. This includes additional considerations such as inequality and cost impact considerations (see <a href="#niceng243er10.appl">Appendix L</a> for full details).</p><p>In the NICE second stage assessment, the committee further scrutinised the Woodcock recommendations and confirmed that they are up to date, in line with current practice and unlikely to change in the near future as no new significant research was being conducted in this area. Although the guideline was found to lack patient views, the committee did not have any concerns about its compatibility with cultures and no health inequality issues were identified. The guideline did not include any health economic evidence or economic modelling. In addition, no economic evaluations were identified in the health economic literature review for the NICE guideline nor was it feasible to undertake any economic modelling. Therefore, unit costs were presented to the committee to aid consideration of cost-effectiveness.</p><p>The Woodcock recommendations were found to be of high quality using the AGREE II tool, as well as acceptable and applicable to the NHS setting using the NICE second stage assessment of recommendations. Therefore, the committee were confident in cross-referring to Woodcock guidelines for recommendations on glucocorticoid supplementation in the pre- intra- and postoperative period.</p></div><div id="niceng243er10.s1.2.2.2"><h5>Children under 16yrs</h5><p>The BSPED guideline<a class="bibr" href="#niceng243er10.ref7" rid="niceng243er10.ref7"><sup>7</sup></a> scored 100% for stakeholder involvement as it was developed by a multidisciplinary group including paediatric endocrinologists, a paediatric endocrinology trainee, paediatric endocrinology clinical nurse specialists and a paediatric pharmacist. The BSPED guideline committee had also sought feedback and input from a variety of stakeholders including clinical specialist society members and patient groups. In addition, the guideline was developed in the UK and was directly applicable to NHS settings. The committee agreed that although other guidelines did include some recommendations for children, the BSPED guideline, in addition to scoring highly in the priority domains, was also more comprehensive, clearly laid out and easy to follow. The committee decided that rather than duplicate the efforts, a cross referral to the BSPED recommendations would be the best option. Therefore, in order to increase their confidence in the BSPED recommendations a second stage assessment of the guideline recommendations was conducted using the NICE process for assessing applicability and acceptability (see <a href="#niceng243er10.appm">Appendix M</a> for full details).</p><p>In the NICE second stage assessment, the paediatric specialists committee members reviewed the BSPED recommendations and agreed that they are up to date and in line with current clinical practice. The committee did not anticipate any constraints or barriers to implementation as the recommendations were in line with current clinical practice. In addition, no health inequality issues were identified. They did not have any concerns about compatibilities with cultures and values and no health inequality issues were identified. They noted that no health economic evidence or economic modelling was considered but were aware from the literature review that no economic evaluations were identified. Therefore, unit costs were presented to the committee to aid consideration of cost-effectiveness.</p><p>Overall, the BSPED guideline was considered to be of high quality using the AGREE II tool, as well as acceptable and applicable to the NHS setting using the NICE second stage assessment of recommendations. Therefore, the committee were confident in cross-referring to the BSPED website recommendations for pharmacological management at times of physiological stress in children and young people (sections 2-5).</p><p>The committee recognised that there is limited data directly comparing outcomes between different glucocorticoid supplementation strategies at times of physiological stress. They wanted to highlight the importance in the post-operative period for in-patients undergoing invasive procedures. Further research comparing these different strategies may provide evidence of benefit of one strategy over the other in terms of the clinical and cost effectiveness. This would help clinicians develop the most effective and pragmatic approach to adrenal replacement during major stress. Therefore, the committee made a research recommendation in this regard (see <a href="#niceng243er10.appn">Appendix N</a>).</p></div></div><div id="niceng243er10.s1.2.3"><h4>1.2.3. Benefits and harms</h4><div id="niceng243er10.s1.2.3.1"><h5>Adults</h5><p>All of the reviewed guidelines included recommendations on the importance of patient education on sick-day rules and the provision of additional supplies of glucocorticoids to cover periods of physiological stress. This was in line with committee recommendations that had already been discussed as part of the information and support review. Therefore, the committee made a cross-reference to those recommendations (see review A information and support and recommendations in section 1.1 of the guideline).. The committee highlighted that some people find it difficult to obtain additional supplies of corticosteroids and it is important that health professionals are aware of the importance of this to prevent adrenal crisis. They also highlighted that additional supplies of hydrocortisone should be provided in an immediate release formulation even to people who are on the modified release formulation to ensure faster replacement of cortisol levels.</p><p>The committee discussed that there is variation in practice regarding doubling a dose of hydrocortisone versus increasing the frequency of dosing. They recommended an increase to at least 40 mg a day because on balance this is easier for people to manage. The committee agreed a dose of oral hydrocortisone 2-4 times a day is the preferred option because it’s a shorter-acting glucocorticoid. However, the committee noted that significant intercurrent illness such as fever > 39°C, diarrhoea and vomiting, 4 times a day would be preferential. Four times a day is preferable because diarrhoea and vomiting means that hydrocortisone will not be absorbed adequately leading to a significant risk of adrenal crisis.</p><p>The committee discussed that for emergency management, hydrocortisone should be given as this is a lifesaving replacement therapy with no toxic dose. Therefore, the benefits of taking it far outweighed the risk of not taking it and having a potentially fatal adrenal crisis. However, , the committee wanted to highlight that increasing dosing too frequently or for prolonged periods of time can lead to symptoms of glucocorticoid excess such as Cushing’s syndrome. They were unable to define the duration of the increase in dosing as this varied according to the type of physiological stress and factors related to the individual.</p><p>For people who are already taking 10 mg of oral prednisolone, the committee did not recommend increasing the dose but considered splitting it into 2 equal doses across the day. This is to ensure there is some glucocorticoid cover over 24 hours because there can be a loss of diurnal variation in cortisol overnight in intercurrent illness.</p><p>The committee discussed that if absorption of oral glucocorticoids is difficult due to vomiting and/or diarrhoea then an injection of intramuscular or intravenous hydrocortisone could be given and medical help should be sought. Admission to hospital may be required and treatment should be provided in accordance with recommendations on emergency management (see section 1.7 of the guideline).</p><p>For adults having planned or emergency or invasive medical procedures, the committee endorsed the recommendations from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. The committee decided to cross refer to this as the two-stage quality assessment using AGREE II and the NICE checklist had increased their confidence in the recommendations and they agreed that they reflected current practice. The recommendations are summarised in tables 1 and 2 of the guideline (Woodcock et al).</p><div id="niceng243er10.s1.2.3.1.1"><h5>Children under 16yrs</h5><p>The committee reviewed the recommendations from the BSPED guideline<a class="bibr" href="#niceng243er10.ref8" rid="niceng243er10.ref8"><sup>8</sup></a> and found them to be in line with their clinical expertise. They agreed that as the BSPED guideline was methodologically robust and had achieved high scores using the AGREE tool and the NICE second stage assessment checklist, a cross-reference should be made to the BSPED website recommendations for pharmacological management of physiological stress (sections 2-5).</p></div></div><div id="niceng243er10.s1.2.3.2"><h5>Pregnancy care</h5><p>There was limited evidence for women or people with adrenal insufficiency who are pregnant or planning pregnancy. Where guidelines made recommendations on pregnancy, an increase in glucocorticoid dosing was recommended particularly during the third trimester and labour. Therefore, the committee made consensus recommendations based on their experience, current best practice and the expert advice of a co-opted Consultant Obstetrician, Gynaecologist & Maternal Medicine Specialist.</p><p>Normal pregnancy is associated with increases in cortisol binding globulin (oestrogen induced), total plasma cortisol, free cortisol and aldosterone which combat the anti-glucocorticoid and anti-mineralocorticoid effect of progesterone, and therefore continuation of replacement doses of glucocorticoid and mineralocorticoid are essential in pregnancy to prevent adrenal crisis. Despite these increases in cortisol and aldosterone which are more apparent by the third trimester, few women with adrenal insufficiency routinely require increases in their replacement steroid doses. Clinical signs including symptoms of adrenal insufficiency, postural hypotension and hyponatraemia justify increases in replacement doses. Indiscriminate increases in glucocorticoids can result in unnecessary steroid excess which can cause maternal complications. Minimal hydrocortisone or prednisolone crosses the placenta to the foetus as they are inactivated by placental 11β-hydroxysteroid dehydrogenase. The committee noted it was important to advise women on the safety of hydrocortisone during pregnancy.</p><p>Sick-day rules apply in pregnancy as they do outside pregnancy. Many women will experience nausea and vomiting during pregnancy and may not be able to keep their medications down. Advice on taking glucocorticoids during periods of pregnancy related vomiting should be provided.. Some women experience hyperemesis gravidarum (HG) where nausea and vomiting are associated with pre-pregnancy weight loss, dehydration and electrolyte imbalance requiring intravenous fluid replacement and anti-emetics. Many units manage HG in an ambulatory setting. This is not appropriate for those with adrenal insufficiency who will usually require parenteral replacement of increased doses of replacement steroids, intravenous fluid replacement and closer monitoring of blood pressure and serum electrolytes, more suited to an inpatient setting.</p><p>For guidance during the birth, the committee reviewed the recommendations on steroid replacement regimens within the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies and agreed to cross-refer to this.</p><p>Glucocorticoid requirements decline following delivery and if replacement doses have been increased in pregnancy, they should be decreased to pre-pregnancy levels providing no complications which may require continuation of increased dosing.</p><p>Due to the limited research evidence in this area, the committee agreed to make a research recommendation (see Appendix <a href="#niceng243er10.appn.et1">N.1</a>).</p></div></div><div id="niceng243er10.s1.2.4"><h4>1.2.4. Cost effectiveness and resource use</h4><p>No economic evaluations were identified for this review therefore unit costs were presented to aid the committee’s consideration of cost-effectiveness, these were the daily and monthly costs of hydrocortisone, prednisolone, and dexamethasone.</p><p>The committee made recommendations reflective of best clinical practice. They noted that best clinical practice is not current practice for all and fatalities as a result of people experiencing adrenal crisis in periods of physiological stress have occurred due to the lack of sick-day dosing. The committee noted that in instances where best clinical practice is not being employed – providing people with additional medication to cover periods of physiological stress is highly likely to be a cost-effective strategy. People with adrenal insufficiency experiencing physiological stress are at increased risk of adrenal crisis, which is not only life-threatening but also incurs high costs to the NHS as these people will most likely require a hospital admission. This hospital admission will include the cost of an inpatient stay in addition to intravenous hydrocortisone and fluids. These recommendations are not expected to have a significant resource impact.</p><p>No specific recommendation was made on the sick-day dosing regimen for those on dexamethasone as they considered that very few people are on this drug and therefore the dosing should decided upon on a case by case. It was noted that people who normally take modified release hydrocortisone, they should receive a prescription of immediate release hydrocortisone for the purposes of sick-day dosing. The sick-day dosing recommendations included recommendations to admit a person to hospital during periods of physiological stress if they are unable to absorb oral glucocorticoids, for example, during prolonged diarrhoea and vomiting; and give 100 mg intramuscular or intravenous hydrocortisone. There is a cost associated with an admission to hospital, however the committee highlighted that this was necessary to avert the risk of adrenal crisis, which is not only life-threatening but also incurs high costs to the NHS as these people will most likely require a hospital admission.</p><p>For those already in hospital for another reason and are severely unwell (for example with sepsis or in intensive care) they also would require intravenous or intramuscular hydrocortisone. The committee noted that health care professionals should consider seeking endocrinology specialist advice for these people as they may require further guidance on sick-day dosing.</p><p>Recommendations were made relating specifically to pregnancy care. These were based on committee expert opinion and overall reflect current practice and therefore are not expected to result in a significant resource impact. The exception to this is the recommendation to manage hyperemesis gravidarum in an inpatient setting rather than an outpatient setting. This is not current practice and the committee noted that deaths have been reported following outpatient management of hyperemesis gravidarum in people with adrenal insufficiency. The committee highlighted the importance of inpatient care and noted that although this is more costly than outpatient care, the population for whom this recommendation would apply is small and therefore this should not result in a significant resource impact. It was also noted that once vomiting is controlled, hyperemesis gravidarum can be managed in an outpatient setting with anti-emetics.</p></div><div id="niceng243er10.s1.2.5"><h4>1.2.5. Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.4.1 – 1.4.9 and 1.4.12 – 1.4.21 and the recommendation for research on the clinical and cost-effectiveness of glucocorticoid treatment in the post-operative period for people with known or at risk of adrenal insufficiency undergoing in-patient invasive procedures.</p></div></div></div><div id="niceng243er10.rl.r1"><h2 id="_niceng243er10_rl_r1_">References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="niceng243er10.ref1">Araujo Castro
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M, Curras Freixes
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M, de Miguel Novoa
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P, Gracia Gimeno
|
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P, Alvarez Escola
|
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C, Hanzu
|
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FA. SEEN guidelines for the management and prevention of acute adrenal insufficiency. Endocrinologia, diabetes y nutricion. 2020; 67(1):53–60
|
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[<a href="https://pubmed.ncbi.nlm.nih.gov/31003863" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31003863</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="niceng243er10.ref2">Arlt
|
|
W. Society for Endocrinology endocrine emergency guidance: Emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients. Endocrine connections. 2016; 5(5):G1–G3
|
|
[<a href="/pmc/articles/PMC5314805/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5314805</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27935813" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27935813</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>3.</dt><dd><div class="bk_ref" id="niceng243er10.ref3">BMJ Group and the Royal Pharmaceutical Society of Great Britain. British National Formulary. 2023. Available from: <a href="https://bnf.nice.org.uk/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://bnf<wbr style="display:inline-block"></wbr>​.nice.org.uk/</a> Last accessed: 05/11/2023.</div></dd></dl><dl class="bkr_refwrap"><dt>4.</dt><dd><div class="bk_ref" id="niceng243er10.ref4">Bornstein
|
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SR, Allolio
|
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B, Arlt
|
|
W, Barthel
|
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A, Don-Wauchope
|
|
A, Hammer
|
|
GD
|
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et al. Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism. 2016; 101(2):364–389
|
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[<a href="/pmc/articles/PMC4880116/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4880116</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26760044" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26760044</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>5.</dt><dd><div class="bk_ref" id="niceng243er10.ref5">Glowniak
|
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JV, Loriaux
|
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DL. A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Surgery. 1997; 121(2):123–129
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[<a href="https://pubmed.ncbi.nlm.nih.gov/9037222" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9037222</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>6.</dt><dd><div class="bk_ref" id="niceng243er10.ref6">Husebye
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ES, Allolio
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B, Arlt
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W, Badenhoop
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K, Bensing
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S, Betterle
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C
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et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. Journal of Internal Medicine. 2014; 275(2):104–115
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[<a href="https://pubmed.ncbi.nlm.nih.gov/24330030" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24330030</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>7.</dt><dd><div class="bk_ref" id="niceng243er10.ref7">Mushtaq
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T, Ali
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SR, Boulos
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N, Boyle
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R, Cheetham
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T, Davies
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JH
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et al. Emergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance. Archives of Disease in Childhood. 2023; 108(11):871–878
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[<a href="/pmc/articles/PMC10646833/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC10646833</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/37045585" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 37045585</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>8.</dt><dd><div class="bk_ref" id="niceng243er10.ref8">National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. London. National Institute for Health and Care Excellence, 2014. Available from: <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.nice.org<wbr style="display:inline-block"></wbr>​.uk/process/pmg20/chapter/introduction</a> [<a href="https://pubmed.ncbi.nlm.nih.gov/26677490" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26677490</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>9.</dt><dd><div class="bk_ref" id="niceng243er10.ref9">Simpson
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H, Tomlinson
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J, Wass
|
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J, Dean
|
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J, Arlt
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W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London, England). 2020; 20(4):371–378
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[<a href="/pmc/articles/PMC7385786/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7385786</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32675141" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32675141</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>10.</dt><dd><div class="bk_ref" id="niceng243er10.ref10">Speiser
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PW, Arlt
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W, Auchus
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RJ, Baskin
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LS, Conway
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GS, Merke
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DP
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et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: An Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 2018; 103(11):4043–4088
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[<a href="/pmc/articles/PMC6456929/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6456929</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30272171" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30272171</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>11.</dt><dd><div class="bk_ref" id="niceng243er10.ref11">Woodcock
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T, Barker
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P, Daniel
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S, Fletcher
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S, Wass
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JAH, Tomlinson
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JW
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et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020; 75(5):654–663
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[<a href="https://pubmed.ncbi.nlm.nih.gov/32017012" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32017012</span></a>]</div></dd></dl></dl></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng243er10.appa"><h3>Appendix A. Review protocols</h3><p id="niceng243er10.appa.et1"><a href="/books/NBK609020/bin/niceng243er10-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">A.1. Review protocol for pharmacological management at times of physiological stress</a><span class="small"> (PDF, 220K)</span></p><p id="niceng243er10.appa.et2"><a href="/books/NBK609020/bin/niceng243er10-appa-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">A.2. Health economic review protocol</a><span class="small"> (PDF, 136K)</span></p></div><div id="niceng243er10.appb"><h3>Appendix B. Literature search strategies</h3><p>The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.<a class="bibr" href="#niceng243er10.ref8" rid="niceng243er10.ref8"><sup>8</sup></a></p><p>For more information, please see the <a href="/books/NBK609020/bin/NG243-Methods.pdf">Methodology</a> review published as part of the accompanying documents for this guideline.</p><p id="niceng243er10.appb.et1"><a href="/books/NBK609020/bin/niceng243er10-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.1. Clinical search literature search strategy</a><span class="small"> (PDF, 196K)</span></p><p id="niceng243er10.appb.et2"><a href="/books/NBK609020/bin/niceng243er10-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.2. Health Economics literature search strategy</a><span class="small"> (PDF, 171K)</span></p></div><div id="niceng243er10.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng243er10.appc.et1"><a href="/books/NBK609020/bin/niceng243er10-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Figure 1. Flow chart of clinical study selection for the review of pharmacological management at times of physiological stress</a><span class="small"> (PDF, 110K)</span></p></div><div id="niceng243er10.appd"><h3>Appendix D. Effectiveness evidence</h3><p id="niceng243er10.appd.et1"><a href="/books/NBK609020/bin/niceng243er10-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (159K)</span></p></div><div id="niceng243er10.appe"><h3>Appendix E. Forest plots</h3><p id="niceng243er10.appe.et1"><a href="/books/NBK609020/bin/niceng243er10-appe-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">E.1. Hydrocortisone vs placebo</a><span class="small"> (PDF, 159K)</span></p></div><div id="niceng243er10.appf"><h3>Appendix F. GRADE tables</h3><p id="niceng243er10.appf.et1"><a href="/books/NBK609020/bin/niceng243er10-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (213K)</span></p></div><div id="niceng243er10.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng243er10.appg.et1"><a href="/books/NBK609020/bin/niceng243er10-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (201K)</span></p></div><div id="niceng243er10.apph"><h3>Appendix H. Economic evidence tables</h3><p>None</p></div><div id="niceng243er10.appi"><h3>Appendix I. Health economic model</h3><p>No original health economic modelling was undertaken for this review question.</p></div><div id="niceng243er10.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng243er10.appj.s1"><h4>J.1. Clinical studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng243er10appjtab1"><a href="/books/NBK609020/table/niceng243er10.appj.tab1/?report=objectonly" target="object" title="Table 10" class="img_link icnblk_img" rid-ob="figobniceng243er10appjtab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng243er10.appj.tab1"><a href="/books/NBK609020/table/niceng243er10.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng243er10appjtab1">Table 10</a></h4><p class="float-caption no_bottom_margin">Studies excluded from the clinical review. </p></div></div></div><div id="niceng243er10.appj.s2"><h4>J.2. Health Economic studies</h4><p>None.</p></div></div><div id="niceng243er10.appk"><h3>Appendix K. AGREE II reviewer scoring</h3><p id="niceng243er10.appk.et1"><a href="/books/NBK609020/bin/niceng243er10-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (241K)</span></p></div><div id="niceng243er10.appl"><h3>Appendix L. Woodcock et al: Discussion points for assessing recommendations pharmacological management at times of physiological stress</h3><p id="niceng243er10.appl.et1"><a href="/books/NBK609020/bin/niceng243er10-appl-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (110K)</span></p></div><div id="niceng243er10.appm"><h3>Appendix M. BSPED - Discussion points for assessing recommendations on pharmacological management at times of physiological stress</h3><p id="niceng243er10.appm.et1"><a href="/books/NBK609020/bin/niceng243er10-appm-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (156K)</span></p></div><div id="niceng243er10.appn"><h3>Appendix N. Recommendation for research</h3><p id="niceng243er10.appn.et1"><a href="/books/NBK609020/bin/niceng243er10-appn-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">N.1. Research question</a><span class="small"> (PDF, 179K)</span></p></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence reviews underpinning recommendations 1.4.1 to 1.4.9 and 1.4.12 to 1.4.21 and recommendation for research 5 in the NICE guideline</p><p>This evidence review was developed by NICE</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://www.gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2024.</div><div class="small"><span class="label">Bookshelf ID: NBK609020</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/39541490" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">39541490</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng243er10tab1"><div id="niceng243er10.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">PICO characteristics of review question</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng243er10.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng243er10.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with adrenal insufficiency (primary, secondary, or tertiary)</td></tr><tr><th id="hd_b_niceng243er10.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng243er10.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<b>Glucocorticoids:</b>
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</p>
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<p>Any preparation, any dose and any route of administration of the following:
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<ul><li class="half_rhythm"><div>Hydrocortisone</div></li><li class="half_rhythm"><div>Prednisolone</div></li><li class="half_rhythm"><div>Dexamethasone</div></li></ul>
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Exclusions:</p>
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<p>Hydrocortisone acetate</p>
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<p>Long-acting methylprednisolone</p>
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<p>Prednisone (not used in the UK)</p>
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<p>For management of hypoglycaemia – specific to children
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<ul><li class="half_rhythm"><div>Dextrose any dose/concentration glucose oral or iv any dose/concentration usually 20% or hypogel in children</div></li></ul></p>
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</td></tr><tr><th id="hd_b_niceng243er10.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng243er10.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><b>For glucocorticoids:</b>
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<ul><li class="half_rhythm"><div>Different doses</div></li><li class="half_rhythm"><div>Compared to each other</div></li><li class="half_rhythm"><div>Routes of administration</div></li></ul>
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<b>For Glucose for management of hypoglycaemia</b>
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<ul><li class="half_rhythm"><div>Different doses or concentrations</div></li></ul></td></tr><tr><th id="hd_b_niceng243er10.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng243er10.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Mortality</div></li><li class="half_rhythm"><div>Health-related quality of life, for example EQ-5D, SF-36</div></li><li class="half_rhythm"><div>Incidence of adrenal crisis</div></li><li class="half_rhythm"><div>Acute adverse events of drugs: (up to 2 weeks- if none at this follow up include shortest follow up time reported in paper)</div></li><li class="half_rhythm"><div>Long term cumulative adverse effects:</div></li><li class="half_rhythm"><div>Admission to hospital</div></li><li class="half_rhythm"><div>Admission to ITU</div></li><li class="half_rhythm"><div>Length of hospital stay.</div></li><li class="half_rhythm"><div>Readmission to hospital</div></li><li class="half_rhythm"><div>Psychological morbidities e.g., Incidence of stress or PTSD</div></li><li class="half_rhythm"><div>Adverse effects of hypoglycaemia e.g., neurological damage, seizures,</div></li><li class="half_rhythm"><div>Adverse effects of hyponatraemia e.g., neurological damage, seizures,</div></li></ul></td></tr><tr><th id="hd_b_niceng243er10.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</th><td headers="hd_b_niceng243er10.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Systematic reviews of RCTs and RCTs. If not enough RCT data, non-randomised studies adjusting for at least 3-3 of the following confounders: age, sex, smoking, weight/BMI, time to treatment, doses (timing or actual dose), Iv vs im administration, comorbidities e.g., heart disease, diabetes, kidney disease. Practice guidelines that include recommendations on pharmacological management of physiological stress</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng243er10tab2"><div id="niceng243er10.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of studies included in the evidence review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng243er10.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng243er10.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng243er10.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention and comparison</th><th id="hd_h_niceng243er10.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><th id="hd_h_niceng243er10.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comments</th></tr></thead><tbody><tr><td headers="hd_h_niceng243er10.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Glowniak 1997</b>
|
|
<a class="bibr" href="#niceng243er10.ref5" rid="niceng243er10.ref5">
|
|
<sup>5</sup>
|
|
</a>
|
|
</p>
|
|
<p>Double blind RCT</p>
|
|
<p>USA</p>
|
|
</td><td headers="hd_h_niceng243er10.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=17</p>
|
|
<p>(18 surgical procedures)</p>
|
|
<p>Secondary AI</p>
|
|
<p>All male patients</p>
|
|
<p>Patients who had been taking at least 7.5 mg prednisone daily for several months and had secondary adrenal insufficiency as defined by adrenocorticotropic hormone testing (determined by results of cosyntropin testing) and who were undergoing major surgical procedures.</p>
|
|
<p>Conditions being treated with prednisone included: Rheumatoid arthritis, COPD, Crohn’s disease, post-liver transplant, idiopathic thrombacytopenic purpura, demyelinating spastic pamparesis.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Steroid-treated group</b>
|
|
</p>
|
|
<p>
|
|
<b>n=6</b>
|
|
</p>
|
|
<p>
|
|
<u>Before the start of operation:</u>
|
|
</p>
|
|
<p>intravenous injection of 100 mg cortisol in normal saline solution 1 hour before the start of the operation</p>
|
|
<p>
|
|
<u>After operation:</u>
|
|
</p>
|
|
<p>Iv injection 25 mg cortisol given every 6 hours for 2 days and then every 12 hours for 1 day (total of 10 postoperative injections). This regimen supplies 200 mg cortisol for the first 24 hours after operation, 100 mg cortisol on second day after operation and 50 mg on the third day in addition to patients’ normal daily dose of prednisone.</p>
|
|
<p>
|
|
<b>Placebo group</b>
|
|
</p>
|
|
<p>
|
|
<b>n=12</b>
|
|
</p>
|
|
<p>Identical injection amounts of normal saline solution.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Lowest blood pressure (BP) during operation</p>
|
|
<p>Change in BP during operation.</p>
|
|
<p>Highest pulse rate during operation</p>
|
|
<p>Lowest BP in first 3 days after operation</p>
|
|
<p>Other outcomes</p>
|
|
<p>Highest pulse each day after operation</p>
|
|
</td><td headers="hd_h_niceng243er10.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng243er10tab3"><div id="niceng243er10.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Summary of guidelines included in the review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Study</th><th id="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Population</th><th id="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Recommendations included in the guideline</th><th id="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Quality assessment with AGREE II</th></tr></thead><tbody><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Arlt 2016</b>
|
|
<a class="bibr" href="#niceng243er10.ref2" rid="niceng243er10.ref2">
|
|
<sup>2</sup>
|
|
</a>
|
|
</p>
|
|
<p>UK</p>
|
|
<p>Society for Endocrinology Clinical Committee</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults only</p>
|
|
<p>Primary, secondary and tertiary AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p><b>Education of patients and partner/parents</b> regarding symptom awareness and the correct adjustment of glucocorticoid replacement dose:</p>
|
|
<p><b>Sick-Day Rule 1</b>: the need to double daily oral glucocorticoid dose during illness with fever that requires bed rest and/or antibiotics.</p>
|
|
<p>Ensure they have an additional supply of hydrocortisone tablets so that they can double their dose for at least 7 days.</p>
|
|
<p><b>Sick-Day Rule 2</b>: the need to administer glucocorticoids per i.v. or i.m. injection during prolonged vomiting or diarrhoea, during preparation for colonoscopy or in case of acute trauma or surgery.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>69%</b>
|
|
</p>
|
|
<p>The guideline clearly states that the aim is to take the non-specialist through the initial phase of assessment and management of adrenal crisis although the health questions covered were not specifically described. The authors do provide a clear description of the target population.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>The guideline does not report group membership or stakeholder involvement. It does not include target population representation and their views have not been sought.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>This is a consensus guideline and does include any details about methodology.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>92%</b>
|
|
</p>
|
|
<p>Recommendations were clearly stated and unambiguous but lacked details on alternative management strategies.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>4%</b>
|
|
</p>
|
|
<p>The guideline does not provide any information on how the recommendations may be implemented such as facilitators and barriers or potential resource implications.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>There is no statement of funding body or competing interests of the authors.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Araujo-Castro 2020</b>
|
|
<a class="bibr" href="#niceng243er10.ref1" rid="niceng243er10.ref1">
|
|
<sup>1</sup>
|
|
</a>
|
|
</p>
|
|
<p>Spain</p>
|
|
<p>Spanish Society of Endocrinology and Nutrition (SEEN guidelines)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults and children</p>
|
|
<p>Primary, secondary and tertiary AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>The provide a very detailed summary table of the main recommendations on how glucocorticoid doses should be adjusted in relation to stress, pregnancy and various medical or therapeutic procedures (too detailed to reproduce here).</p>
|
|
<p>In summary, the following is recommended:
|
|
<ul><li class="half_rhythm"><div>Increasing the doses of hydrocortisone, sometimes doubling (fever >38oC) or even tripling it (fever >39oC).</div></li><li class="half_rhythm"><div>An awareness of those situations that can trigger hormone deficiency and of the reasons why early treatment is so important.</div></li><li class="half_rhythm"><div>Education and regular follow-up (annually or more often in patients with a recent history of AAI), reviewing how to increase the GC dose according to the severity of intercurrent illness, and when and how to administer hydrocortisone via the intramuscular, subcutaneous, or rectal route at home.</div></li></ul></p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>75 %</b>
|
|
</p>
|
|
<p>The guideline clearly states that it intended to provide practical recommendations for all healthcare professionals who may be involved in the diagnosis, treatment, and prevention of AC. It is also intended to provide patients and their families with action guidelines for AC management and prevention. However, the specific health questions covered were not clearly described.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>36%</b>
|
|
</p>
|
|
<p>Does not report on stakeholder engagement or patient input. However, it does clearly state who the target population is.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>This is a consensus-based guideline but there is no description of the methods used.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>92%</b>
|
|
</p>
|
|
<p>The recommendations are clear and unambiguous with different options for management clearly stated. However, there is no clear distinction of what the key recommendations are.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>The guideline does not provide any information on how the recommendations may be implemented such as facilitators and barriers or potential resource implications.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>The authors state that the development group consists of the Adrenal Disorders Group of the Neuroendocrinology Area of the Spanish Society of Endocrinology and Nutrition (SEEN) was asked to draft the guideline at the proposal of the SEEN’s board. However, no statement of competing interests of the authors is included.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Bornstein 2016</b>
|
|
<a class="bibr" href="#niceng243er10.ref4" rid="niceng243er10.ref4">
|
|
<sup>4</sup>
|
|
</a>
|
|
</p>
|
|
<p>Multinational</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults and children</p>
|
|
<p>Primary AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>For the prevention of adrenal crisis, we suggest adjusting glucocorticoid dose according to severity of illness or magnitude of the stressor.</p>
|
|
<p>We suggest patient education concerning glucocorticoid adjustments in stressful events and adrenal crisis-prevention strategies including parenteral self- or lay-administration of emergency glucocorticoids.</p>
|
|
<p>We recommend that all patients should be equipped with a steroid emergency card and medical alert identification to inform health personnel of the need for increased glucocorticoid doses to avert or treat adrenal crisis and the need of immediate parenteral steroid treatment in the event of an emergency.</p>
|
|
<p>We recommend that every patient should be equipped with a glucocorticoid injection kit for emergency use and be educated on how to use it.</p>
|
|
<p>
|
|
<b>Treatment during pregnancy</b>
|
|
</p>
|
|
<p>We suggest that, based on the individual clinical course, an increase in hydrocortisone dose should be implemented, in particular during the third trimester. (Ungraded best practice statement)</p>
|
|
<p>In pregnant women with PAI, we suggest using hydrocortisone over cortisone acetate, prednisolone, or prednisone and recommend against using dexamethasone because it is not inactivated in the placenta.</p>
|
|
<p>We recommend hydrocortisone stress dosing during the active phase of labour, similar to that used in major surgical stress.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>61%</b>
|
|
</p>
|
|
<p>The authors state that the guideline is on the diagnosis and management of AI. However, the specific health questions and specific populations covered were not clearly described.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>17%</b>
|
|
</p>
|
|
<p>Group membership and stakeholder involvement only included endocrinologists. There was no patient or lay member involvement.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>11%</b>
|
|
</p>
|
|
<p>The guideline document reports that recommendations were based on evidence from systematic reviews and their strength was based on GRADE ratings. However, this is not published and there is no clear description of the review methods. We were unable to find any supplementary materials. Therefore, we were unable to verify this. The document does include a description of the consensus methods used.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>86%</b>
|
|
</p>
|
|
<p>Recommendations were clear and unambiguous. Some management options were provided, and key recommendations were identifiable.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>The guideline does not provide any information on how the recommendations may be implemented such as facilitators and barriers or potential resource implications.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>92%</b>
|
|
</p>
|
|
<p>The guideline states the co-sponsoring associations: which are the European Society of Endocrinology and the American Association for Clinical Chemistry) but does not state if the views of the funding bodies have influenced the content of the guideline.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Mushtaq 2023</b>
|
|
<a class="bibr" href="#niceng243er10.ref7" rid="niceng243er10.ref7">
|
|
<sup>7</sup>
|
|
</a>
|
|
</p>
|
|
<p>UK</p>
|
|
<p>British Society of Paediatric Endocrinology & Diabetes (BSPED) 2022</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Children up to 15 years</p>
|
|
<p>Primary, secondary and tertiary paediatric AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>The authors recommend additional doses of hydrocortisone during intercurrent illness in line with sick-day rules.</p>
|
|
<p>If the child is taking a glucocorticoid at over 30 mg/m2/day of a hydrocortisone equivalent dose, then further sick-day doses with additional hydrocortisone may not be necessary in principle but they should have a bespoke plan for the management of AI. For those on regular prednisolone, our recommendation is for sick-day dosing with hydrocortisone. If this is not practical, then prednisolone 7.5/mg/m2/day given in two divided doses can be used.</p>
|
|
<p>If the existing prednisolone dose is greater than the required sick-day dose, then the prescribed prednisolone should be split into two doses given at 12-hourly intervals. The relatively short half-life of Deflazacort necessitates the use of sick-day dosing with hydrocortisone.</p>
|
|
<p>The authors also provide a detailed table of how to adjust hydrocortisone in different situations from minor procedures to major surgery (too detailed to reproduce here).</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>The authors clearly state that the document aims to provide guidance for intercurrent illness, medical, dental and surgical procedures to allow timely and appropriate recognition and treatment of AI and adrenal crisis for children and young people. In addition, they state the health questions and provide a clear description of the target population.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>The guideline membership consisted of a multidisciplinary group including 12 paediatric endocrinologists, 1 paediatric endocrinology trainee, 2 paediatric endocrinology clinical nurse specialists and 1 paediatric pharmacist.</p>
|
|
<p>Stakeholder involvement including the BPSED clinical and executive committees, the BSPED membership, Society for Endocrinology clinical committee and patient organisations including the CAH support group, Addison’s Disease Self-Help Group and The Pituitary Foundation.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>40%</b>
|
|
</p>
|
|
<p>The guideline states that some literature searches were conducted but there is no information provided on the methods used or the search strategies. It does state that draft consensus recommendations were reviewed by different groups.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>Recommendations were clear and unambiguous and use tables and diagrams to illustrate them. Different management options for specific groups are provided and key recommendations are identifiable.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>25%</b>
|
|
</p>
|
|
<p>The guideline does not discuss facilitators and barriers to implementation or cost implications. However, it does provide useful implementation tools such as the paediatric version of the NHS emergency steroid card.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>67%</b>
|
|
</p>
|
|
<p>A funding statement states that the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.</p>
|
|
<p>A statement on competing interests states that there were none declared. The guideline was commissioned by BSPED but there is no information on how it influenced the recommendations in the guideline.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Husebye 2014</b>
|
|
<a class="bibr" href="#niceng243er10.ref6" rid="niceng243er10.ref6">
|
|
<sup>6</sup>
|
|
</a>
|
|
</p>
|
|
<p>European</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults and children</p>
|
|
<p>Primary AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>The authors provide a detailed table of how to adjust hydrocortisone in different situations from minor procedures to major surgery (too detailed to reproduce here).</p>
|
|
<p>In summary, they recommend that surgery and invasive medical procedures often require intravenous or intramuscular hydrocortisone and increased oral doses. Small adjustments to hydrocortisone and fludrocortisone doses may be needed during pregnancy, particularly during the last trimester; parenteral doses if hydrocortisone should be given during delivery. An increase in hydrocortisone should also be considered if embarking on unaccustomed, intense or prolonged exercise.</p>
|
|
<p>
|
|
<b>Treatment in pregnancy</b>
|
|
</p>
|
|
<p>Surgery and invasive medical procedures often require iv or im HC and increased oral doses. Small adjustments to HC and fludrocortisone doses may be needed during pregnancy, particularly during the last trimester; parenteral doses of hydrocortisone should be given during delivery</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>39%</b>
|
|
</p>
|
|
<p>The document very briefly describes the aim as being the provision of a European Expert Consensus Statement on the diagnosis treatment and follow up of patients with primary AI. The health questions being addressed are not clearly stated.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>14%</b>
|
|
</p>
|
|
<p>The committee only included clinical members didn’t include any patient representatives.</p>
|
|
<p>Some recommendations were based on recommendations from patient groups but these were not the recommendations on emergency management.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>Consensus statement by committee of European clinical experts. No details on methodology are provided.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>56%</b>
|
|
</p>
|
|
<p>Some recommendations are clearly stated and tables are provided for clarity. However, other recommendations and key recommendations are not easily discernible within the document.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>The guideline does not provide any information on how the recommendations may be implemented such as facilitators and barriers or potential resource implications.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>79%</b>
|
|
</p>
|
|
<p>It is clearly stated that some authors are members of the Plenadren International Advisory Board. It also states that guideline was supported by the Journal of Internal Medicine and the FP7 project (Euradrenal; Grant No. 201167). However, it does not state if the views of the funding bodies have influenced the content of the guideline.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Speiser 2018</b>
|
|
<a class="bibr" href="#niceng243er10.ref10" rid="niceng243er10.ref10">
|
|
<sup>10</sup>
|
|
</a>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">This guideline focusses solely on CAH caused by 21-hydroxylase deficiency.</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>In all patients with congenital adrenal hyperplasia who require glucocorticoid treatment, for situations such as febrile illness (>38.5°C), gastroenteritis with dehydration, major surgery accompanied by general anaesthesia, and major trauma we recommend increasing the glucocorticoid dosage.</p>
|
|
<p>In patients with congenital adrenal hyperplasia under everyday mental and emotional stress and minor illness and/or before routine physical exercise we recommend against the use of increased glucocorticoid doses.</p>
|
|
<p>In patients with congenital adrenal hyperplasia who require treatment, we recommend always wearing or carrying medical identification indicating that they have adrenal insufficiency.</p>
|
|
<p>In patients with congenital adrenal hyperplasia, we recommend educating patients and their guardians and close contacts on adrenal crisis prevention and increasing the dose of glucocorticoid (but not mineralocorticoid) during intercurrent illness.</p>
|
|
<p>We recommend equipping every patient with congenital adrenal hyperplasia with a glucocorticoid injection kit for emergency use and providing education on parenteral self-administration (young adult and older) or lay administration (parent or guardian) of emergency glucocorticoids.</p>
|
|
<p>
|
|
<b>Treatment in pregnancy</b>
|
|
</p>
|
|
<p>In women with non-classic congenital adrenal hyperplasia who are infertile or have a history of prior miscarriage, we recommend treatment with a glucocorticoid that does not traverse the placenta.</p>
|
|
<p>In women with congenital adrenal hyperplasia who are pregnant, we advise management by an endocrinologist familiar with congenital adrenal hyperplasia.</p>
|
|
<p>In women with congenital adrenal hyperplasia who become pregnant we recommend continued pre-pregnancy doses of hydrocortisone/ prednisolone and fludrocortisone therapy, with dosage adjustments if symptoms and signs of glucocorticoid insufficiency occur.</p>
|
|
<p>Technical remark: Clinicians should evaluate the need for an increase in glucocorticoid during the second or third trimester and administer stress doses of glucocorticoids during labour and delivery.</p>
|
|
<p>In women with congenital adrenal hyperplasia who are pregnant, or trying to become pregnant, we recommend against using glucocorticoids that traverse the placenta, such as dexamethasone.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>56%</b>
|
|
</p>
|
|
<p>The authors state that the aim of the guideline is to update their previous clinical practice guideline on management of CAH due to steroid 21-hydroxylase deficiency. However, no clear health questions included.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>58%</b>
|
|
</p>
|
|
<p>The Writing Committee consisted of 10 content experts representing the following specialties: endocrinology, paediatric urology, and psychology. Two of the committee members brought an international perspective to this guideline topic. The Writing Committee also included a clinical practice guideline methodologist.</p>
|
|
<p>The guideline was subject to internal and external review to include stakeholder views such as Endocrine Society members, representatives of cosponsoring organisations and an Expert Reviewer.</p>
|
|
<p>However, there is no patient involvement or representation.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>40%</b>
|
|
</p>
|
|
<p>Part of the guideline is evidence based using GRADE but no search strategies or methods for evidence selection are available. Some of the recommendations have considerations of benefits and harms but not the recommendations on stress dosing. There is a clear description of the internal and external review process and how views were taken into account in the final guideline document. Where there was evidence a description of the link to recommendations was included.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>72%</b>
|
|
</p>
|
|
<p>Recommendations were clear and key recommendations identifiable. There weren’t many suggested management options for different situation.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>13%</b>
|
|
</p>
|
|
<p>The guideline didn’t include any discussion of facilitators and barriers or consideration of resource impact. There were no criteria for auditing or monitoring.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>This guideline was exceptional in the description of conflicts of interest providing clear statements on how these are used in selection of members and there is also a clear table of each member and the interests they declared. Funding bodies and how they were involved are also clearly stated.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Simpson 2020</b>
|
|
<a class="bibr" href="#niceng243er10.ref9" rid="niceng243er10.ref9">
|
|
<sup>9</sup>
|
|
</a>
|
|
</p>
|
|
<p>UK</p>
|
|
<p>Royal College of Physicians</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults only</p>
|
|
<p>All AI</p>
|
|
<p>(some recommendations for children included)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="6" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Sick-day rule 1</b>
|
|
</p>
|
|
<p>Moderate intercurrent illness (e.g., fever, infection requiring antibiotics), surgical procedure under local anaesthetic.</p>
|
|
<p>Double usual daily glucocorticoid use</p>
|
|
<p>
|
|
<b>Sick-day rule 2</b>
|
|
</p>
|
|
<p>Severe intercurrent illness (eg persistent vomiting from GI viral illnesses), preparation for colonoscopy, acute trauma or surgery</p>
|
|
<p>Hydrocortisone 100 mg intravenously at onset, followed by initiation of a continuous infusion of hydrocortisone 200 mg.24 h-1</p>
|
|
<p>Or hydrocortisone 100 mg intramuscularly followed by 50 mg every 6 h i.m. or i.v.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>81%</b>
|
|
</p>
|
|
<p>The guideline states that the aim is to go through causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. However, the target health questions are not always clearly defined.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>19%</b>
|
|
</p>
|
|
<p>There was some stakeholder involvement through RCP patient safety committee and Society for Endocrinology clinical committee. Also seen by NHSE/I patient safety team.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development</b>
|
|
</p>
|
|
<p>
|
|
<b>8%</b>
|
|
</p>
|
|
<p>Consensus guidelines but no detail of the methodology is included in the document.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>86%</b>
|
|
</p>
|
|
<p>Recommendations were generally clear and key recommendations were easily identifiable and different management options were available.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>19%</b>
|
|
</p>
|
|
<p>While there was no discussion of barriers and facilitators to implementation or any cost impact analysis, the authors have developed a new NHS Steroid Emergency Card (implementation tool) that can be held by patients at risk of adrenal crisis and includes a management summary for the emergency treatment of adrenal crisis alongside a link to the Society for Endocrinology emergency management guidelines.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>0%</b>
|
|
</p>
|
|
<p>There is no statement of funding body or competing interests of the authors.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_1" rowspan="5" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Woodcock 2020</b>
|
|
<a class="bibr" href="#niceng243er10.ref11" rid="niceng243er10.ref11">
|
|
<sup>11</sup>
|
|
</a>
|
|
</p>
|
|
<p>UK</p>
|
|
<p>Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_2" rowspan="5" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Adults and children</p>
|
|
<p>All types of AI</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_3" rowspan="5" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Hydrocortisone 100 mg by intravenous (i.v.) injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone at 200 mg.24 h, until the patient can take double their usual oral glucocorticoid dose by mouth. This regimen is preferred above others due to enhanced safety. This should then be tapered back to the appropriate maintenance dose, in most cases within 48 h, although for up to a week if surgery is more major/complicated clinical judgement should be used to guide this. Intramuscular (i.m.) administration may be prescribed in circumstances where i.v. infusion therapy is impractical.</p>
|
|
<p>The authors also provide a detailed table of how to adjust hydrocortisone in different situations (too detailed to reproduce here).</p>
|
|
<p>
|
|
<b>Treatment in pregnancy</b>
|
|
</p>
|
|
<p>Maternal glucocorticoid supplementation in obstetric patients with adrenal insufficiency represents another group who require special mention; women may require a higher maintenance dose during the later stages of pregnancy (20th week onwards), and stress dose supplementation using hydrocortisone 100 mg at the onset of labour, and then either by continuous i.v. infusion of hydrocortisone 200 mg.24 h-1 or 50 mg intramuscularly every 6 h until after delivery.</p>
|
|
</td><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Scope and Purpose</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>The authors clearly state that the aim is to ensure that patients with adrenal insufficiency are identified and adequately supplemented with glucocorticoids during the peri-operative period. It also clearly states the target population and the expected benefit.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Stakeholder Involvement</b>
|
|
</p>
|
|
<p>
|
|
<b>67%</b>
|
|
</p>
|
|
<p>Group membership and target users are clearly stated. However, there is no indication that stakeholder views were sought.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Rigour of Development 0%</b>
|
|
</p>
|
|
<p>This is a consensus guideline and does not include any details about methodology.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Clarity of Presentation</b>
|
|
</p>
|
|
<p>
|
|
<b>97%</b>
|
|
</p>
|
|
<p>Key recommendations are prominent in the guideline document. More specific recommendations are clearly presented in tables with different management options for different situations.</p>
|
|
<p>
|
|
<b>Applicability</b>
|
|
</p>
|
|
<p>
|
|
<b>6%</b>
|
|
</p>
|
|
<p>The guideline does not provide any information on how the recommendations may be implemented such as facilitators and barriers or potential resource implications.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<b>Editorial Independence</b>
|
|
</p>
|
|
<p>
|
|
<b>100%</b>
|
|
</p>
|
|
<p>The authors clearly state the source of funding (National Institute for Health Research (NIHR) through the Birmingham and Oxford NIHR Biomedical Research Centres) and clarify that the views expressed are those of the authors and not of the sponsors. Competing interests were included in the document (none of the authors had any to declare).</p>
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|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">Table key:: i.v. intraveneous .m. intramustular PAI: Primary Adrenal Insufficiency</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng243er10tab4"><div id="niceng243er10.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">Clinical evidence summary: glucocorticoids versus placebo</span></h3><div class="caption"><p>See <a href="#niceng243er10.appf">Appendix F</a> for full GRADE tables.</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab4_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng243er10.tab4_1_1_1_1" style="text-align:left;vertical-align:bottom;">Outcomes</th><th id="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng243er10.tab4_1_1_1_2" style="text-align:left;vertical-align:bottom;">№ of participants (studies) Follow-up</th><th id="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng243er10.tab4_1_1_1_3" style="text-align:left;vertical-align:bottom;">Certainty of the evidence (GRADE)</th><th id="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="2" colspan="1" headers="hd_h_niceng243er10.tab4_1_1_1_4" style="text-align:left;vertical-align:bottom;">Relative effect (95% CI)</th><th id="hd_h_niceng243er10.tab4_1_1_1_5" colspan="2" rowspan="1" style="text-align:left;vertical-align:bottom;">Anticipated absolute effects</th></tr><tr><th headers="hd_h_niceng243er10.tab4_1_1_1_5" id="hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Risk with placebo</th><th headers="hd_h_niceng243er10.tab4_1_1_1_5" id="hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Risk difference with Hydrocortisone</th></tr></thead><tbody><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Lowest systolic BP during operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>c</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean lowest systolic BP during operation was 102 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 13 mmHg higher</p>
|
|
<p>(13.49 lower to 39.49 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Lowest diastolic BP during operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>d</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean lowest diastolic BP during operation was 63 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 3 mmHg higher</p>
|
|
<p>(10.1 lower to 16.1 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Change in systolic BP during operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>e</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean change in systolic BP during operation was 34 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 5 mmHg higher</p>
|
|
<p>(17.92 lower to 27.92 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Change in diastolic BP during operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>f</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean change in diastolic BP during operation was 18 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 3 mmHg lower</p>
|
|
<p>(14.84 lower to 8.84 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Highest pulse rate during operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>g</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean highest pulse rate during operation was 103 BPM</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 10 BPM lower</p>
|
|
<p>(22.76 lower to 2.76 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Lowest Systolic BP in first 3 days after operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>h</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean lowest Systolic BP in first 3 days after operation was 109 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 3 mmHg higher</p>
|
|
<p>(18.52 lower to 24.52 higher)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Lowest diastolic BP in first 3 days after operation</td><td headers="hd_h_niceng243er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>18</p>
|
|
<p>(1 RCT)</p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>⨁◯◯◯</p>
|
|
<p>Very low<sup>a</sup><sup>,</sup><sup>b</sup><sup>,</sup><sup>i</sup></p>
|
|
</td><td headers="hd_h_niceng243er10.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">-</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">The mean lowest diastolic BP in first 3 days after operation was 69 mmHg</td><td headers="hd_h_niceng243er10.tab4_1_1_1_5 hd_h_niceng243er10.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>MD 3 mmHg lower</p>
|
|
<p>(20.61 lower to 14.61 higher)</p>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>a</dt><dd><div id="niceng243er10.tab4_1"><p class="no_margin">Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process)</p></div></dd></dl><dl class="bkr_refwrap"><dt>b</dt><dd><div id="niceng243er10.tab4_2"><p class="no_margin">Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs</p></div></dd></dl><dl class="bkr_refwrap"><dt>c</dt><dd><div id="niceng243er10.tab4_3"><p class="no_margin">MID = 11 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>d</dt><dd><div id="niceng243er10.tab4_4"><p class="no_margin">MID = 6.5 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>e</dt><dd><div id="niceng243er10.tab4_5"><p class="no_margin">MID = 10.75 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>f</dt><dd><div id="niceng243er10.tab4_6"><p class="no_margin">MID = 5.75 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>g</dt><dd><div id="niceng243er10.tab4_7"><p class="no_margin">MID = 7.75 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>h</dt><dd><div id="niceng243er10.tab4_8"><p class="no_margin">MID = 9.75 (0.5 x median baseline standard deviations)</p></div></dd></dl><dl class="bkr_refwrap"><dt>i</dt><dd><div id="niceng243er10.tab4_9"><p class="no_margin">MID = 8.25 (0.5 x median baseline standard deviations)</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng243er10tab5"><div id="niceng243er10.tab5" class="table"><h3><span class="label">Table 5</span><span class="title">Unit costs for pharmacological interventions for physiological stress in children</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab5/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab5_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource<sup>(a)</sup></th><th id="hd_h_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Dose per day</th><th id="hd_h_niceng243er10.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per day</th><th id="hd_h_niceng243er10.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per month</th></tr></thead><tbody><tr><th headers="hd_h_niceng243er10.tab5_1_1_1_1" id="hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<i>Hydrocortisone</i>
|
|
</th><th headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_h_niceng243er10.tab5_1_1_1_3 hd_h_niceng243er10.tab5_1_1_1_4" id="hd_b_niceng243er10.tab5_1_1_1_2" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
|
<i>8mg/m<sup>2</sup> - 15 mg/m<sup>2</sup></i>
|
|
</th></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Neonate</b>
|
|
</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2mg – 2.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2mg – 2.5mg<sup>(b)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.29</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£8.68</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alkindi</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2mg – 2.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2.70 - £3.38</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£82.13 - £102.66</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">n/a</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>1 year</b>
|
|
</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3.5mg – 4.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3.5mg – 4.5mg<sup>(b)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.29</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£8.68</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alkindi</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3.5mg – 4.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£4.73 - £6.08</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£143.72 - £184.78</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3.5mg – 4.5mg<sup>(c)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2.04 - £3.39</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£62.02 - £103.08</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>2 years</b>
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</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4.5mg – 5.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4.5mg – 5.5mg<sup>(b)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.29</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£8.68</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alkindi</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">n/a</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4.5mg – 5.5mg<sup>(d)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.39 - £4.74</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£103.08 - £144.14</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>5 years</b>
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</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6mg – 7.5mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6mg – 7.5mg<sup>(b)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alkindi</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">n/a</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6mg – 7.5mg<sup>(e)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£5.41 - £4.75</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£164.68 - £144.57</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>10 years</b>
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|
</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9mg – 11mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9mg – 11mg<sup>(f)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21 - £2.17</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51 - £66.10</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alkindi</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">n/a</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9mg – 11mg<sup>(g)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.51 - £3.52</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£106.73 - £107.16</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>12 years</b>
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</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9.5mg – 12mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9.5mg – 12mg<sup>(f)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21 - £2.17</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51 - £66.10</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9.5mg – 12mg<sup>(h)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£4.18 - £4.87</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£127.26 - £148.22</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>14 years</b>
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|
</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">12mg – 15mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">12mg – 15mg<sup>(i)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21 - £2.97</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51 - £90.28</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">12mg<sup>(j)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£4.87</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£148.22</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>16 years</b>
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</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">13mg – 17mg</td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Standard release</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">13mg – 17mg<sup>(i)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21 - £2.97</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51 - £90.28</td></tr><tr><td headers="hd_h_niceng243er10.tab5_1_1_1_1 hd_b_niceng243er10.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Combination</td><td headers="hd_h_niceng243er10.tab5_1_1_1_2 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">13mg – 17mg<sup>(k)</sup></td><td headers="hd_h_niceng243er10.tab5_1_1_1_3 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.54 - £3.57</td><td headers="hd_h_niceng243er10.tab5_1_1_1_4 hd_b_niceng243er10.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£107.58 - £108.48</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng243er10.tab5_1"><p class="no_margin">Source of costs from The British National Formulary (BNF);<a class="bibr" href="#niceng243er10.ref3" rid="niceng243er10.ref3"><sup>3</sup></a> date accessed: 05/11/2023. Dosage based committee expert opinion. For children over 1 year assumed the largest dose is given in the morning and the smallest in the evening, mimicking the normal daily rhythm of cortisol secretion.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(b)</dt><dd><div id="niceng243er10.tab5_2"><p class="no_margin">One 10mg tablet used for each dose, assuming four doses daily until age 4 and three doses daily from age 5. Each tablet is crushed and dissolved in water allowing for correct dose to be drawn up and administered. For older children tablets can be split to make up doses. Assumes drug wastage.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(c)</dt><dd><div id="niceng243er10.tab5_3"><p class="no_margin">3.5mg costed as one 2.5mg standard release tablet and 1mg Alkindi granules in capsules; 4.5mg costs as one 2.5mg standard release tablet and 2 mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(d)</dt><dd><div id="niceng243er10.tab5_4"><p class="no_margin">4.5mg costs as one 2.5mg standard release tablet and 2mg Alkindi granules in capsules;5.5mg costed as one 2.5mg standard release tablet and 3mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(e)</dt><dd><div id="niceng243er10.tab5_5"><p class="no_margin">6mg costs as one 2.5mg standard release tablet and 3.5mg Alkindi granules in capsules;7.5mg costed as two 2.5mg standard release tablets and 2.5mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(f)</dt><dd><div id="niceng243er10.tab5_6"><p class="no_margin">Either one 10mg tablet used for each dose, assuming three doses daily, tablets can be split to make up doses or 10mg costed as one 5mg and two 2.5mg standard release tablets.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(g)</dt><dd><div id="niceng243er10.tab5_7"><p class="no_margin">9mg costs as one 2.5mg and one 5mg standard release tablets and 1.5mg Alkindi granules in capsules;11mg costed as one 5mg and two 2.5mg standard release tablets and 1mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(h)</dt><dd><div id="niceng243er10.tab5_8"><p class="no_margin">9.5mg costs as one 2.5mg and one 5mg standard release tablets and 2mg Alkindi granules in capsules;12mg costed as one 5mg and two 2.5mg standard release tablets and 2mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(i)</dt><dd><div id="niceng243er10.tab5_9"><p class="no_margin">Either one 10mg tablet used for each dose, assuming three doses daily, tablets can be split to make up doses or 15mg costed as two 5mg and two 2.5mg standard release tablets.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(j)</dt><dd><div id="niceng243er10.tab5_10"><p class="no_margin">Costed as one 5mg and two 2.5mg standard release tablets and 2mg Alkindi granules in capsules.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(k)</dt><dd><div id="niceng243er10.tab5_11"><p class="no_margin">13mg costs as three 2.5mg and one 5mg standard release tablets and 0.5mg Alkindi granules in capsules;17mg costed as one 10mg and one 5mg standard release tablets and 2mg Alkindi granules in capsules.</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng243er10tab6"><div id="niceng243er10.tab6" class="table"><h3><span class="label">Table 6</span><span class="title">Unit costs for pharmacological interventions for physiological stress in adults</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.tab6/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.tab6_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Resource<sup>(a)</sup></th><th id="hd_h_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Dose per day</th><th id="hd_h_niceng243er10.tab6_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Cost per day</th><th id="hd_h_niceng243er10.tab6_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Cost per month</th></tr></thead><tbody><tr><th headers="hd_h_niceng243er10.tab6_1_1_1_1" id="hd_b_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Hydrocortisone</i>
|
|
</th><th headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_h_niceng243er10.tab6_1_1_1_3 hd_h_niceng243er10.tab6_1_1_1_4" id="hd_b_niceng243er10.tab6_1_1_1_2" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
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<i>15mg – 25mg</i>
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<sup>
|
|
(b)
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|
</sup>
|
|
</th></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as one and a half 10mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.11</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.25</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as two 10mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15mg – 20mg<sup>(c)</sup></td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.14</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£4.34</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as one 10mg tablet and one 15mg tablet a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.19</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£36.23</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as three 10mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15-mg – 25mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.21</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.51</td></tr><tr><th headers="hd_h_niceng243er10.tab6_1_1_1_1" id="hd_b_niceng243er10.tab6_1_1_6_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Modified release hydrocortisone (Plenadren)</i>
|
|
</th><th headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_h_niceng243er10.tab6_1_1_1_3 hd_h_niceng243er10.tab6_1_1_1_4" id="hd_b_niceng243er10.tab6_1_1_6_2" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
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<i>15mg – 25mg</i>
|
|
</th></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_6_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as three 5mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£14.55</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£442.56</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_6_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as four 5mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£19.40</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£590.08</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_6_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as one 20mg tablet a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£8.00</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£243.33</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_6_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as one 5mg tablet and one 20mg tablet a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£12.85</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_6_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£390.85</td></tr><tr><th headers="hd_h_niceng243er10.tab6_1_1_1_1" id="hd_b_niceng243er10.tab6_1_1_11_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Prednisolone</i>
|
|
</th><th headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_h_niceng243er10.tab6_1_1_1_3 hd_h_niceng243er10.tab6_1_1_1_4" id="hd_b_niceng243er10.tab6_1_1_11_2" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
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<i>3mg – 6mg</i>
|
|
</th></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_11_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as three 1mg tablets a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.08</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2.51</td></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_11_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prescribed as one 1mg tablet and one 5mg tablet a day</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6mg</td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.06</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_11_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.86</td></tr><tr><th headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_h_niceng243er10.tab6_1_1_1_2 hd_h_niceng243er10.tab6_1_1_1_3 hd_h_niceng243er10.tab6_1_1_1_4" id="hd_b_niceng243er10.tab6_1_1_14_1" colspan="4" rowspan="1" style="text-align:left;vertical-align:top;">
|
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<i>Dexamethasone</i>
|
|
</th></tr><tr><td headers="hd_h_niceng243er10.tab6_1_1_1_1 hd_b_niceng243er10.tab6_1_1_14_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Dexamethasone</td><td headers="hd_h_niceng243er10.tab6_1_1_1_2 hd_b_niceng243er10.tab6_1_1_14_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.25mg – 0.5mg<sup>(d)</sup></td><td headers="hd_h_niceng243er10.tab6_1_1_1_3 hd_b_niceng243er10.tab6_1_1_14_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.05 - £0.10</td><td headers="hd_h_niceng243er10.tab6_1_1_1_4 hd_b_niceng243er10.tab6_1_1_14_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.59 - £3.18</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng243er10.tab6_1"><p class="no_margin">Source of costs from The British National Formulary (BNF);<a class="bibr" href="#niceng243er10.ref3" rid="niceng243er10.ref3"><sup>3</sup></a> date accessed: 05/10/2023</p></div></dd></dl><dl class="bkr_refwrap"><dt>(b)</dt><dd><div id="niceng243er10.tab6_2"><p class="no_margin">Standard release hydrocortisone is taken either 2 or 3 times a day.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(c)</dt><dd><div id="niceng243er10.tab6_3"><p class="no_margin">For a 15mg dose of hydrocortisone the additional 5mg is wasted.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(d)</dt><dd><div id="niceng243er10.tab6_4"><p class="no_margin">Cost available in the BNF is for 0.5mg per day. The cost for 0.25mg a day assumes people take half a 0.5mg tablet daily and there is no drug wastage.</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng243er10appjtab1"><div id="niceng243er10.appj.tab1" class="table"><h3><span class="label">Table 10</span><span class="title">Studies excluded from the clinical review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK609020/table/niceng243er10.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng243er10.appj.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reasons for exclusion</th></tr></thead><tbody><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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Arafah, Baha M (2020) Perioperative Glucocorticoid Therapy for Patients with Adrenal Insufficiency: Dosing Based on Pharmacokinetic Data. The Journal of clinical endocrinology and metabolism
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105(3) [<a href="https://pubmed.ncbi.nlm.nih.gov/31996925" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31996925</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not contain outcomes of interest</p>
|
|
<p>
|
|
<i>Pharmacokinetic outcomes e.g., cortisol half life</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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Aso, K., Izawa, M., Higuchi, A.
|
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et al. (2009) Stress doses of glucocorticoids cannot prevent progression of all adrenal crises. Clinical Pediatric Endocrinology
|
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18(1): 23–27
|
|
[<a href="/pmc/articles/PMC4004880/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4004880</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24790376" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24790376</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not include a multivariate analysis</p>
|
|
<p>
|
|
<i>Retrospective analysis of 24 cases of adrenal crises in 9 patients with no multivariate analyses.</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Bannon, C. A., Gallacher, D., Hanson, P.
|
|
et al. (2020) Systematic review and meta-analysis of the metabolic effects of modified-release hydrocortisone versus standard glucocorticoid replacement therapy in adults with adrenal insufficiency. Clinical Endocrinology
|
|
93(6): 637–651
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/32621327" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32621327</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Systematic review used as source of primary studies</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Blavin, L. R. and French, L. (1997) Perioperative steroids for secondary adrenal insufficiency. Journal of Family Practice
|
|
44(6): 532–3
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/9191621" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9191621</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Commentary article</p>
|
|
<p>
|
|
<i>Summary and comment on Glowniak</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Britt, R.C., Devine, A., Swallen, K.C.
|
|
et al. (2006) Corticosteroid use in the intensive care unit: At what cost?. Archives of Surgery
|
|
141(2): 145–149
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/16490890" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16490890</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Bromberg, J S, Baliga, P, Cofer, J B
|
|
et al. (1995) Stress steroids are not required for patients receiving a renal allograft and undergoing operation. Journal of the American College of Surgeons
|
|
180(5): 532–6
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/7749527" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 7749527</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Commentary article</p>
|
|
<p>
|
|
<i>Summary and commentary on Glowniak 1997</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Burger-Stritt, Stephanie, Kardonski, Pavel, Pulzer, Alina
|
|
et al. (2018) Management of adrenal emergencies in educated patients with adrenal insufficiency-A prospective study. Clinical endocrinology
|
|
89(1): 22–29
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/29617051" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29617051</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study design not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Chacko, Shireen R, Abraham, Ananth P, Asha, Hesarghatta Shyamasunder
|
|
et al. (2020) Selective perioperative steroid supplementation protocol in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Acta neurochirurgica
|
|
162(10): 2381–2388
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/32772164" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32772164</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study design not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Chihaoui, M., Mimita, W., Oueslati, I.
|
|
et al. (2020) Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial. Endocrine
|
|
67(1): 155–160
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/31552584" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31552584</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not contain an intervention relevant to this review protocol</p>
|
|
<p>
|
|
<i>Study compares prednisolone to hydrocortisone during fasting. No stress dosing.</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
El-Maouche, Diala, Hargreaves, Courtney J, Sinaii, Ninet
|
|
et al. (2018) Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients with Congenital Adrenal Hyperplasia. The Journal of clinical endocrinology and metabolism
|
|
103(6): 2336–2345
|
|
[<a href="/pmc/articles/PMC6276663/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6276663</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29584889" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29584889</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not contain an intervention relevant to this review protocol</p>
|
|
<p>
|
|
<i>Intervention is stress dosing education.</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
El-Sibai, Katia, Rajpal, Aman, Al-Aridi, Ribal
|
|
et al. (2017) The impact of peri-operative dexamethasone administration on the normal hypothalamic pituitary adrenal response to major surgical procedures. Endocrine
|
|
58(1): 134–142
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/28865040" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28865040</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Population not relevant to this review protocol</p>
|
|
<p>
|
|
<i>Participants with normal HPA function</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Fleming, Louise Kathleen; Rapp, Carla Gene; Sloane, Rick (2011) Caregiver knowledge and self-confidence of stress dosing of hydrocortisone in children with congenital adrenal hyperplasia. Journal of pediatric nursing
|
|
26(6): e55–60
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/22055384" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22055384</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not contain an intervention relevant to this review protocol</p>
|
|
<p>- Population not relevant to this review protocol</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Key, S J, Hodder, S C, Davies, R
|
|
et al. (2003) Perioperative corticosteroid supplementation and dento-alveolar surgery. Dental update
|
|
30(6): 316–20
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/12955953" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12955953</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study design not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Marik, P. E. and Varon, J. (2008) Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Archives of Surgery
|
|
143(12): 1222–6
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/19075176" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19075176</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Systematic review used as source of primary studies</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Miller, C. S.; Little, J. W.; Falace, D. A. (2001) Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem. Journal of the American Dental Association
|
|
132(11): 1570–9quiz1596
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/11806072" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11806072</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Systematic review used as source of primary studies</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Miller, Netanella, Asali, Aula Atamna, Agassi-Zaitler, Moran
|
|
et al. (2019) Physiological and psychological stress responses to labor and delivery as expressed by salivary cortisol: a prospective study. American journal of obstetrics and gynecology
|
|
221(4): 351e1–351e7 [<a href="https://pubmed.ncbi.nlm.nih.gov/31254523" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31254523</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Mouri, Hideyuki, Jo, Taisuke, Matsui, Hiroki
|
|
et al. (2020) Impact of glucocorticoid supplementation on reducing perioperative complications in patients on long-term glucocorticoid medication: A propensity score analysis using a nationwide inpatient database. American journal of surgery
|
|
220(3): 648–653
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/32067706" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32067706</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Population not relevant to this review protocol</p>
|
|
<p>
|
|
<i>Patients on long term glucocorticoid supplementation but excludes patients who had adrenal insufficiency at admission.</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Nilsson, A. G., Marelli, C., Fitts, D.
|
|
et al. (2014) Prospective evaluation of long-term safety of dual-release hydrocortisone replacement administered once daily in patients with adrenal insufficiency. European Journal of Endocrinology
|
|
171(3): 369–77
|
|
[<a href="/pmc/articles/PMC4106399/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4106399</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24944332" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24944332</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study does not contain an intervention relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Owa, Takao, Mimura, Kazuya, Kakigano, Aiko
|
|
et al. (2017) Pregnancy outcomes in women with different doses of corticosteroid supplementation during labor and delivery. The journal of obstetrics and gynaecology research
|
|
43(7): 1132–1138
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/28422424" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28422424</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Plener, Paul L, Zohsel, Katrin, Hohm, Erika
|
|
et al. (2017) Lower cortisol level in response to a psychosocial stressor in young females with self-harm. Psychoneuroendocrinology
|
|
76: 84–87
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/27889466" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27889466</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Simunkova, K., Jovanovic, N., Rostrup, E.
|
|
et al. (2016) Effect of a pre-exercise hydrocortisone dose on short-term physical performance in female patients with primary adrenal failure. European Journal of Endocrinology
|
|
174(1): 97–105
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/26494876" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26494876</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Study does not contain outcomes of interest</p>
|
|
<p>
|
|
<i>Looks at effects of stress dosing on physical performance and outcomes are all exercise performance related.</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Wang, Xiao, Heinrich, Daniel A, Kunz, Sonja L
|
|
et al. (2021) Characteristics of preoperative steroid profiles and glucose metabolism in patients with primary aldosteronism developing adrenal insufficiency after adrenalectomy. Scientific reports
|
|
11(1): 11181
|
|
[<a href="/pmc/articles/PMC8160266/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC8160266</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/34045650" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 34045650</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study does not contain an intervention relevant to this review protocol.</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Weise, M., Drinkard, B., Mehlinger, S. L.
|
|
et al. (2004) Stress dose of hydrocortisone is not beneficial in patients with classic congenital adrenal hyperplasia undergoing short-term, high-intensity exercise. Journal of Clinical Endocrinology & Metabolism
|
|
89(8): 3679–84
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/15292287" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15292287</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Data not reported in an extractable format or a format that can be analysed</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Whittle, E. and Falhammar, H. (2019) Glucocorticoid Regimens in the Treatment of Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. Journal of the Endocrine Society
|
|
3(6): 1227–1245
|
|
[<a href="/pmc/articles/PMC6546346/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6546346</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31187081" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31187081</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Systematic review used as source of primary studies</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Yau, Mabel, Jacob, Marianne, Orton, Sarah
|
|
et al. (2021) Perioperative stress dose steroid management of children with classical congenital adrenal hyperplasia: Too much or too little?. Journal of pediatric urology
|
|
17(5): 654e1–654e6 [<a href="https://pubmed.ncbi.nlm.nih.gov/34266748" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 34266748</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Study does not contain outcomes of interest</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Zaghiyan, Karen N, Murrell, Zuri, Melmed, Gil Y
|
|
et al. (2012) High-dose perioperative corticosteroids in steroid-treated patients undergoing major colorectal surgery: necessary or overkill?. American journal of surgery
|
|
204(4): 481–6
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/22748293" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22748293</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Zaghiyan, Karen, Melmed, Gil, Murrell, Zuri
|
|
et al. (2011) Are high-dose perioperative steroids necessary in patients undergoing colorectal surgery treated with steroid therapy within the past 12 months?. The American surgeon
|
|
77(10): 1295–9
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/22127073" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22127073</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr><tr><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Zaghiyan, Karen, Melmed, Gil, Murrell, Zuri
|
|
et al. (2012) Safety and feasibility of using low-dose perioperative intravenous steroids in inflammatory bowel disease patients undergoing major colorectal surgery: A pilot study. Surgery
|
|
152(2): 158–63
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/22503320" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22503320</span></a>]
|
|
</td><td headers="hd_h_niceng243er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Population not relevant to this review protocol</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
|
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<script type="text/javascript" src="/portal/portal3rc.fcgi/rlib/js/InstrumentNCBIBaseJS/InstrumentPageStarterJS.js"> </script>
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<script type="text/javascript" src="//static.pubmed.gov/portal/portal3rc.fcgi/4216699/js/3968615.js" snapshot="books"></script></body>
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</html>
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