What are the common symptoms of adrenal insufficiency after sudden cessation of corticosteroids (cortisone) after prolonged use?

Common Presenting Complaints After Sudden Cessation of Cortisone

Sudden cessation of cortisone after prolonged use commonly presents with weakness, fatigue, loss of appetite, weight loss, nausea, vomiting, diarrhea, and abdominal pain - symptoms that can mimic the underlying disease for which steroids were initially prescribed. 1

Clinical Presentation of Adrenal Insufficiency After Steroid Withdrawal

Primary Symptoms

• Weakness and fatigue
• Loss of appetite (anorexia)
• Weight loss
• Nausea and vomiting
• Diarrhea
• Abdominal pain
• Hypotension (especially orthostatic)

Additional Manifestations

• Hypoglycemia
• Hyponatremia
• Hyperkalemia
• Impaired cognitive function (confusion, disorientation)
• Muscle pain or cramps
• Dehydration

Pathophysiology

Corticosteroid withdrawal syndrome occurs due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis from exogenous glucocorticoids. This condition:

• Is under-recognized, occurring in approximately 50% of patients tested immediately after withdrawal of medium or high-dose prednisolone used for long periods 1
• Can occur with any route of administration, with intra-articular injections showing particularly high risk (52.2%) 2
• May persist for extended periods - even after 4 years of withdrawal from prednisolone in some cases 3

Risk Factors for Severe Adrenal Insufficiency

The likelihood of developing significant symptoms increases with:

• Higher doses of corticosteroids
• Longer duration of treatment (>1 year showing 27.4% risk) 2
• Abrupt rather than gradual withdrawal
• Underlying conditions requiring high-dose steroids (hematological malignancies showing 60% risk) 2

Clinical Pearls and Pitfalls

Important Considerations

• Symptoms can easily be mistaken for recurrence of the underlying condition for which steroids were initially prescribed
• No administration form, dosing, treatment duration, or underlying disease completely eliminates the risk of adrenal insufficiency 2
• Adrenal insufficiency can be life-threatening if not recognized and treated promptly

Common Pitfalls

• Failing to recognize that even low-dose or inhaled corticosteroids can cause adrenal insufficiency 4
• Attributing nonspecific symptoms to other causes rather than considering adrenal insufficiency
• Not having a low threshold for testing patients with suspicious symptoms after steroid withdrawal 2

Management Algorithm for Suspected Adrenal Insufficiency

1. Recognition of at-risk patients:

   • Any patient who has suddenly stopped corticosteroids after prolonged use
   • Patients with vague symptoms after tapering or changing corticosteroid type

2. Initial evaluation:

   • Early morning serum cortisol
   • Electrolytes (looking for hyponatremia, hyperkalemia)
   • Blood glucose (looking for hypoglycemia)

3. For severe symptoms:

   • Immediate treatment with hydrocortisone 100 mg IV/IM
   • IV fluid resuscitation with 0.9% saline
   • Treatment of precipitating conditions 1

4. For confirmed adrenal insufficiency:

   • Replacement therapy following principles for central adrenal insufficiency
   • Patient education on stress dosing and emergency management
   • Medical alert identification

Remember that adrenal insufficiency after corticosteroid withdrawal is common but frequently unrecognized, with potentially serious consequences for morbidity and mortality if not properly identified and treated.