As the use of prednisone to treat various medical illnesses has expanded, so has the concern for hypothalamic-pituitary-adrenal (HPA) axis suppression and subsequent adrenal insufficiency (AI). Despite the fact that most clinicians clearly recognize the potential for AI, many find the sometimes subtle presentation challenging. Furthermore, clinicians often struggle with assessing the likelihood of perioperative AI risk and with preventing it. The following module will address the perioperative management of both patients with known AI and those at risk for HPA axis suppression.

To provide hospitalists with current information and guidelines for the treatment of adrenal insufficiency.

This module is intended for hospitalists. No prerequisites required.

After completing the module, the participant should be able to:

1. Recall the hypothalamic-pituitary-adrenal (HPA) axis and the function of the normal adrenal gland [MK].
2. Identify the symptoms of adrenal insufficiency (AI), the diseases/conditions which cause it, and the typical replacement therapy [PC, MK].
3. Design a strategy to risk-stratify patients for postoperative AI complications based on history and the likely surgical stress [PC, PB].
4. Formulate a plan to risk-stratify patients for postoperative AI complications based on HPA axis testing [PC, MK, SB].
5. Choose treatments to prevent postoperative AI complications [PC] and develop a systematic approach to the preoperative evaluation to enhance the diagnosis of AI [PC, SB, IC].

Accreditation Council for Graduate Medical Education General Competency Assignments

PC Patient Care

MK Medical Knowledge

IC Interpersonal & Communication Skills

PR Professionalism

SB Systems-Based Practice

PB Practice-Based Learning & Improvement

Source: Accreditation Council for Graduate Medical Education. Common Program Requirements: General Competencies. Available at: http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf. Published: September 28, 1999. Accessed December 4, 2009.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

Accreditation Statement: The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement: The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)^™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release date: December 15, 2009. Expiration date: December 15, 2011.

Estimated time to complete activity: 2 hours

Full Disclosure Policy Affecting CME Activities: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any relevant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The presenting faculty reported the following:

^*Professor of Medicine, Department of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.

Conflict of Interest: Dr Johnson reports having no relevant financial or advisory relationships with corporate organizations related to this activity.

Off-Label Product Discussion: The author has indicated that he has not referenced unlabeled or unapproved uses of drugs or devices.

Disclaimer: The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

Address correspondence to: Bruce E. Johnson, MD, Professor of Medicine, Department of Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Roanoke, VA 24016. E-mail bejohnson@carilionclinic.org.

Click here to download the references for this educational activity.

The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of 3 sections: an unaccredited pre-test, a study activity, and a CME post-test. All 3 sections must be completed to receive CME credit.

Supported by an educational grant from Merck & Co., Inc.