Guidelines consensus "Adrenal gland disease" clinical response guidelines for novel coronavirus infection

Source: Endocrinology Branch of Chinese Medical Association

Abstract: Adrenal diseases such as adrenal insufficiency and adrenal tumors/hyperplasia combined with novel coronavirus infection bring great challenges
to disease management.
In order to improve the management of adrenal gland disease during the novel coronavirus infection, we have made some management recommendations based on the available evidence to guide the treatment
of patients with adrenal gland disease during the epidemic.

Patients with adrenal disorders often have endocrine hormonal disturbances and tumor mass effects, involving multidisciplinary management and follow-up
.
There is currently no clinical evidence of direct damage to the adrenal glands by the new coronavirus, but studies have shown that there may be some disturbances in adrenal function
.
Adrenal disorders include adrenal tumors/hyperplasias (leading to imbalances in sugar, lipid, water-salt metabolism, refractory hypertension, immunosuppression, etc.
), as well as adrenal insufficiency from various causes, requiring long-term glucocorticoid replacement, poor stress reserve, and high
chance of infection.
These may affect the treatment and management of new coronavirus infections, bringing great challenges
.
In order to further standardize the comprehensive management of adrenal gland diseases under new crown infection, our expert team has formulated the following clinical response guidelines
.
Adrenal gland disease combined with new crown infection, its new crown treatment can follow the "Diagnosis and Treatment Plan for Novel Coronavirus Pneumonia (Trial Version 9)"
.

First, adrenal insufficiency combined with new crown infection adrenal insufficiency

Adrenal insufficiency combined with new crown infection Adrenal insufficiency can be divided into two categories: primary and secondary, primary due to adrenal autoimmunity, infection, tumor, insufficient blood supply, surgical trauma, radiotherapy and chemotherapy, drugs, congenital diseases and other reasons
.
Secondary, due to hypothalamic-pituitary lesions caused by insufficient secretion of CRH or ACTH, resulting in adrenal cortex atrophy, long-term glucocorticoid replacement therapy
is required.
The clinical manifestations after new crown infection are similar to those in the acute phase of adrenal insufficiency, and aggravate adrenal insufficiency, and even adrenal crisis occurs
.
We recommend that all patients with known/potential adrenal insufficiency carry a disease record plate indicating the type of disease and treatment drugs so that the rescuer can quickly judge and deal with
it.
In the state of stress such as high fever in the new crown infection, in addition to anti-infection, glucocorticoids should be increased on the original basis
.
It is recommended that the body temperature be below 38 ° C to maintain the original dose; 38~39 °C increase to the original dose 2-4 times; 39~40 °C increase to the original dose of 5~9 times
.
Intravenous glucocorticoid infusion, preferably hydrocortisone, is recommended, along with gastrointestinal protectants
.
If accompanied by gastrointestinal dysfunction, hypotension, electrolyte imbalance, consciousness disorders and other adrenal crisis manifestations, or combined with severe and critical new crown infection, glucocorticoid dose should be appropriately increased
.
After stress, glucocorticoids can be reduced by 1/3~1/2 per day for several days until the maintenance amount, and when it is close to the maintenance amount, the reduction rate and amplitude should be slowed down
.

Second, Cushing's syndrome combined with new crown infection

Cushing's syndrome is essentially endogenous hypercortisol
.
Cushing has a new crown infection, because high levels of glucocorticoids may reduce the "flu-like symptoms"
of infected people.
However, Cushing's syndrome is often accompanied by glucose, lipid metabolism and electrolyte disorders, refractory hypertension, malnutrition, immunocompromise, and secondary bacterial and fungal infections after new crown infection, which increases the difficulty
of treatment.
Adequate nutrition and sleep should be ensured to coordinate treatment, and anti-infective therapy should be started early for better outcomes
.

Third, primary aldosteronism (protoaldehyde) combined with new crown infection

Protoaldehyde is due to excessive aldosterone secretion by the adrenal cortex, sodium and water retention, resulting in increased
blood pressure.
Treatment should follow the Expert Consensus on the Diagnosis and Treatment of Primary Aldosteronism 2020.

Antialdosteronism drugs can be temporarily given during infection, and the goals of blood pressure and potassium control are the same
as those of ordinary protoaldehyde patients.
However, some studies have shown that new crown infection is prone to hyponatremia, and the dose of
antihypertensive drugs should be adjusted in time.

4.
Pheochromocytoma/paraganglioma

Pheochromocytoma/paraganglioma is a catecholamine-secreting tumor with refractory/paroxysmal hypertension with headache, sweating, and palpitations as the main clinical manifestations, which can lead to fatal cardiovascular complications
.
Treatment should follow the Expert Consensus on the Diagnosis and Treatment of Pheochromocytoma and Paraganglioma 2020 Edition
.
Antihypertensive therapy with α receptor blockers is recommended in addition to volume expansion during infection
.
The target for blood pressure control < 140/90 mmHg, with fewer<b13> episodes of paroxysmal hypertension.

5.
Adrenal cortical carcinoma and metastatic pheochromocytic tumor

Adrenal malignant tumors combined with new crown infection require multidisciplinary joint diagnosis and treatment by endocrinology and oncology to determine the treatment plan
.
Adequate nutrition and sleep should be ensured to coordinate treatment, and anti-infective therapy
should be started as soon as possible.
Tumor-targeted drug therapy may present with hand-foot syndrome and diarrhoea; Immunotherapy may cause multiple organ damage, which needs to be distinguished from the symptoms of new crown infection and inflammatory damage, and multidisciplinary joint diagnosis and treatment should be organized in time, and surgery and drug intervention should be organized if necessary
.

6.
Precautions for anti-new coronavirus drug treatment

Anti-coronavirus drugs may weaken the therapeutic effect or increase side effects of commonly used drugs for adrenal gland disease, and the interaction between the two drugs must be closely
monitored.
Such as eplerenone, simvastatin, lovastatin, etc.
need to be adjusted in time, and communicate
with the pharmacist if necessary.

Members of the expert group that developed this guide (listed below by last name stroke):

Wang Weiqing Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Ning Guang Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Mu Yiming, Chinese General Hospital of the People's Liberation Army

Cheng Jinluo Changzhou Second People's Hospital affiliated to Nanjing Medical University

Zhu Dalong Drum Tower Hospital Affiliated to Nanjing University School of Medicine

Liu Libin Union Hospital, Fujian Medical University

Liu Jianmin Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

Sun Shouyue Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Li Ling Shengjing Hospital Affiliated to China Medical University

Xiao Haipeng The First Affiliated Hospital of Sun Yat-sen University

Zhongyan Shan The First Affiliated Hospital of China Medical University

Zhao Zhigang Zhengzhou Summer Hospital, Henan University

Zhao Jiajun Affiliated Provincial Hospital of Shandong First Medical University

Ji Qiuhe Xijing Hospital, Air Force Military Medical University

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