From the Guidelines
Adrenal insufficiency after abrupt prednisone cessation requires prompt diagnosis and treatment with immediate glucocorticoid replacement, typically hydrocortisone 50-100mg IV every 6-8 hours for severe cases or oral prednisone 5-7.5mg daily for milder cases, as recommended by the most recent guidelines 1. Diagnosis involves recognizing symptoms like fatigue, weakness, nausea, abdominal pain, hypotension, and electrolyte abnormalities, followed by laboratory testing including morning cortisol levels, ACTH stimulation test, and basic metabolic panel.
- Key symptoms to recognize include:
- Fatigue
- Weakness
- Nausea
- Abdominal pain
- Hypotension
- Electrolyte abnormalities Treatment begins with immediate glucocorticoid replacement, and fluid resuscitation with normal saline is essential for hypotensive patients.
- Initial treatment options include:
- Hydrocortisone 50-100mg IV every 6-8 hours for severe cases
- Oral prednisone 5-7.5mg daily for milder cases After stabilization, patients should be transitioned to maintenance therapy, usually oral hydrocortisone 15-25mg daily in divided doses or prednisone 5mg daily.
- Maintenance therapy options include:
- Oral hydrocortisone 15-25mg daily in divided doses
- Prednisone 5mg daily Long-term management requires gradual tapering of corticosteroids when discontinuing therapy, with typical tapers reducing dose by 2.5-5mg every 1-2 weeks depending on prior dose and duration, as suggested by 1. Patients need education about stress dosing during illness or surgery, typically doubling or tripling their maintenance dose, and should be aware of the need for a medical alert bracelet or necklace for adrenal insufficiency, as emphasized by 1 and 1. Adrenal insufficiency occurs because exogenous corticosteroids suppress the hypothalamic-pituitary-adrenal axis, causing adrenal gland atrophy and inability to produce sufficient cortisol when steroids are abruptly stopped, particularly after courses longer than 3 weeks or at doses exceeding 20mg prednisone daily, as explained by 1 and 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 This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy following large doses for prolonged periods; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.
The diagnostic approach for adrenal insufficiency after abrupt cessation of prednisone therapy involves monitoring for signs and symptoms of adrenal insufficiency, such as fatigue, weight loss, hypotension, and electrolyte imbalances.
- Key steps in the diagnostic approach include:
- Obtaining a thorough medical history, including the duration and dose of prednisone therapy
- Performing physical examinations to assess for signs of adrenal insufficiency
- Ordering laboratory tests, such as cortisol levels and electrolyte panels, to confirm the diagnosis
- Treatment for adrenal insufficiency after abrupt cessation of prednisone therapy typically involves reinstitution of hormone therapy, such as corticosteroids, to replace the deficient hormones. The dose and duration of treatment will depend on the individual patient's needs and the severity of the adrenal insufficiency. In situations of stress, such as illness or surgery, the dose of corticosteroids may need to be increased to prevent adrenal crisis 2 2.
From the Research
Diagnostic Approach
- Adrenal insufficiency is a syndrome of cortisol deficiency, categorized as primary, secondary, or glucocorticoid-induced 3
- The condition should be suspected in patients who have recently tapered or discontinued a supraphysiological dose of glucocorticoids, such as prednisone 3, 4
- Early-morning measurements of serum cortisol, corticotropin, and dehydroepiandrosterone sulfate (DHEAS) are used to diagnose adrenal insufficiency 3
- Patients with primary adrenal insufficiency typically have low morning cortisol levels, high corticotropin levels, and low DHEAS levels 3
- Patients with secondary and glucocorticoid-induced adrenal insufficiency typically have low or intermediate morning cortisol levels and low or low-normal corticotropin and DHEAS levels 3
Treatment
- Treatment of adrenal insufficiency involves supplemental glucocorticoids, such as hydrocortisone or prednisone 3, 5
- Mineralocorticoids, such as fludrocortisone, should be added for patients with primary adrenal insufficiency 3, 5
- Patients with adrenal insufficiency should be instructed on how to increase glucocorticoids during acute illness and prescribed injectable glucocorticoids to prevent or treat adrenal crisis 3, 5
- Stress dose corticosteroid supplementation can improve ventilator weaning and clinical outcome in patients with adrenal insufficiency 6
Special Considerations
- Adrenal insufficiency can be triggered by certain medications or substances, such as bulking agents like psyllium, which can interfere with gastrointestinal absorption of glucocorticoids 7
- Patients with adrenal insufficiency require permanent dose adjustment during different somatic situations, and insufficient glucocorticoid doses can result in adrenal crisis 7
- Early identification and appropriate supplementation with stress dose hydrocortisone can increase the success of ventilator weaning and shorten the weaning period in patients with respiratory failure 6