What is the management for adrenal insufficiency due to abrupt discontinuation of steroids (corticosteroids)?

From the Guidelines

The management of adrenal insufficiency due to abrupt discontinuation of steroids requires immediate reinstitution of corticosteroids, with hydrocortisone 100mg intravenously as a bolus, followed by a continuous infusion of hydrocortisone at 200 mg.24 h-1, until the patient can take double their usual oral glucocorticoid dose by mouth, as recommended by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.

Key Considerations

• The hypothalamic-pituitary-adrenal axis is suppressed by exogenous steroids, leading to adrenal atrophy and inability to produce sufficient cortisol when steroids are suddenly stopped.
• Patients with primary adrenal insufficiency are at risk of adrenal crisis and require stress doses of hydrocortisone during the peri-operative period.
• The dose of hydrocortisone administered should be higher in patients taking drugs that induce CYP3A4, and in obese adults, with a high index of suspicion for adrenal crises in these patients 1.
• Dexamethasone is not adequate as glucocorticoid treatment in patients with primary adrenal insufficiency due to its lack of mineralocorticoid activity.

Management Approach

• Administer hydrocortisone 100mg intravenously as a bolus, followed by a continuous infusion of hydrocortisone at 200 mg.24 h-1.
• Once the patient can take oral medication, transition to double their usual oral glucocorticoid dose, and then taper gradually over weeks to months depending on the duration of prior steroid use.
• Monitor for symptoms of adrenal insufficiency, including fatigue, weakness, nausea, vomiting, hypotension, and electrolyte abnormalities.
• Educate patients about stress dosing during illness and provide medical alert identification.

Tapering Strategy

• For patients on steroids longer than 3 weeks, a typical taper might reduce the dose by 5-10mg every 1-2 weeks until reaching physiologic replacement (equivalent to prednisone 5mg daily), then more slowly thereafter.
• The gradual taper allows time for the adrenal glands to recover function and resume normal cortisol production.

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.

The management for adrenal insufficiency due to abrupt discontinuation of steroids (corticosteroids) involves reinstitution of hormone therapy in situations of stress. To minimize the risk of adrenocortical insufficiency, a gradual reduction of dosage is recommended when withdrawing corticosteroids. If the patient is receiving steroids already, dosage may have to be increased in situations of stress. Key points to consider:

• Gradual reduction of dosage to minimize adrenocortical insufficiency
• Reinstitution of hormone therapy in situations of stress
• Increased dosage may be necessary in situations of stress if the patient is already receiving steroids 2

From the Research

Management of Adrenal Insufficiency

The management of adrenal insufficiency due to abrupt discontinuation of steroids (corticosteroids) involves several key steps:

• Diagnosis: Early-morning measurements of serum cortisol, corticotropin, and dehydroepiandrosterone sulfate (DHEAS) are used to diagnose adrenal insufficiency 3.
• Treatment: Supplemental glucocorticoids, such as hydrocortisone or prednisone, are used to treat adrenal insufficiency 3, 4.
• Mineralocorticoids: Patients with primary adrenal insufficiency may require mineralocorticoids, such as fludrocortisone, in addition to glucocorticoids 3.
• Education: Patients with adrenal insufficiency should be educated on how to increase glucocorticoids during acute illness and prescribed injectable glucocorticoids to prevent or treat adrenal crisis 3, 5.

Prevention of Adrenal Crisis

To prevent adrenal crisis, patients with adrenal insufficiency should:

• Carry an emergency kit with injectable glucocorticoids 3.
• Wear a medical alert bracelet or necklace 5.
• Inform their healthcare provider about their condition and treatment regimen 5.
• Be aware of the signs and symptoms of adrenal crisis, such as hypotension, shock, and altered mental status 3.

Special Considerations

When discontinuing oral glucocorticoids, the following considerations should be taken into account:

• Risk factors for adrenal suppression, such as high doses or prolonged use of glucocorticoids, should be identified 6.
• Adrenal gland testing, such as basal cortisol levels and adrenocorticotropic hormone stimulation tests, may be necessary to confirm adrenal suppression 6.
• A gradual tapering of glucocorticoids may be necessary to minimize the risk of adrenal insufficiency 6.