Does abrupt discontinuation of corticosteroids (steroids) cause adrenal insufficiency (adrenal suppression)?

From the Guidelines

Suddenly stopping steroid medication can indeed cause adrenal suppression, which is why a gradual tapering schedule is typically recommended. When a person takes corticosteroids for more than a few weeks, their body naturally reduces its own cortisol production as it adapts to the external steroid supply 1. This adaptation means the adrenal glands become temporarily "lazy" or suppressed. If steroids are stopped abruptly, the body may not have enough time to resume normal cortisol production, potentially leading to adrenal insufficiency with symptoms including fatigue, weakness, nausea, vomiting, low blood pressure, and in severe cases, adrenal crisis.

Key Considerations

• The risk of adrenal suppression increases with higher doses, longer duration of use (generally more than 3 weeks), and more potent steroids.
• For patients who have been on steroids for extended periods, tapering schedules typically involve gradually reducing the dose over weeks or sometimes months, depending on the original dose and duration.
• The exact tapering schedule should be determined by a healthcare provider based on individual circumstances, as the body needs time to gradually resume its natural cortisol production 1.

Warning Signs and Prevention

• Patients receiving prolonged courses of corticosteroids should be warned about possible steroid withdrawal syndrome, including non-specific symptoms such as weakness, nausea and arthralgia 1.
• A tapering course is recommended when stopping corticosteroids to prevent adrenal suppression and steroid withdrawal syndrome 1.

From the FDA Drug Label

Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment. Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage

Adrenal Suppression: Stopping a steroid suddenly can cause adrenal suppression.

• Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids.
• This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy.
• Gradual reduction of dosage can minimize the risk of adrenal suppression 2, 2, 2.

From the Research

Adrenal Suppression after Stopping Steroid Treatment

• Stopping steroid treatment suddenly can cause adrenal suppression, as the body's natural production of cortisol is suppressed by the exogenous steroid administration 3, 4.
• The risk of adrenal suppression is associated with the dose and duration of steroid treatment, with higher doses and longer treatment durations increasing the risk 4, 5.
• However, even short-term, low-dose steroid treatment can cause adrenal suppression, as shown in studies where patients received steroid treatment for less than 4 weeks or at doses less than 5 mg prednisone equivalent per day 3, 5, 6.
• Adrenal suppression can occur despite following recommended steroid tapering regimens, and a suspicion of steroid-induced adrenal insufficiency requires careful diagnostic workup and prompt introduction of a steroid replacement treatment 3, 4.
• The adrenal response to steroid treatment can be assessed using tests such as the low-dose corticotropin stimulation test, which can help identify patients at risk of adrenal insufficiency 5.

Factors Influencing Adrenal Suppression

• The dose and duration of steroid treatment are important factors influencing the risk of adrenal suppression, with higher doses and longer treatment durations increasing the risk 4, 5.
• Other factors, such as certain medications and comorbidities, can also increase the risk of adrenal suppression 4.
• The type of steroid treatment, such as oral, inhalation, topical, nasal, intra-articular, or intravenous administration, can also affect the risk of adrenal suppression 3.

Recovery of Adrenal Function

• Adrenal function can recover after stopping steroid treatment, but the time to recovery can vary depending on the individual and the treatment regimen 5, 6.
• In some cases, adrenal function may remain suppressed for several months after stopping steroid treatment 5.
• The low-dose corticotropin test can be used to assess the recovery of adrenal function after stopping steroid treatment 5.