What happens if a patient on long-term steroid therapy suddenly stops taking steroids and what labs should be checked?

Management of Adrenal Insufficiency Following Abrupt Steroid Discontinuation

Patients who suddenly stop long-term steroid therapy are at high risk for developing adrenal insufficiency and potentially life-threatening adrenal crisis, requiring immediate hydrocortisone replacement therapy and comprehensive laboratory evaluation. 1

Consequences of Abrupt Steroid Discontinuation

Abrupt discontinuation of long-term systemic steroids can lead to:

• Adrenal insufficiency - The hypothalamic-pituitary-adrenal (HPA) axis becomes suppressed during long-term steroid use, leading to inadequate endogenous cortisol production when steroids are stopped 2, 1
• Adrenal crisis - A life-threatening emergency characterized by hypotension, shock, electrolyte abnormalities, and potentially death 1
• Rebound flare of underlying condition - The original condition being treated may worsen significantly 2

Clinical Presentation

Patients with adrenal insufficiency following steroid withdrawal typically present with:

• Fatigue, weakness, and lethargy
• Nausea, vomiting, abdominal pain
• Hypotension (especially orthostatic)
• Hypoglycemia
• Fever
• Altered mental status (in severe cases)
• Electrolyte abnormalities (hyponatremia, hyperkalemia)

Laboratory Evaluation

The following labs should be checked immediately:

1. Morning cortisol level - Will likely be low (<5 μg/dL) 1
2. ACTH level - To differentiate between primary and secondary adrenal insufficiency (typically low/normal in steroid-induced adrenal insufficiency) 1
3. Electrolytes - Sodium, potassium, chloride, bicarbonate 2, 1
4. Blood glucose - May be low due to impaired gluconeogenesis
5. Complete blood count - To assess for infection
6. ACTH stimulation test - Gold standard for diagnosis, but treatment should not be delayed while awaiting results 1, 3

Immediate Management

1. Start hydrocortisone immediately - Do not wait for confirmatory testing 1

   • IV hydrocortisone 100 mg every 6-8 hours for severe symptoms/adrenal crisis 2, 4
   • Oral hydrocortisone 15-20 mg daily in divided doses (10-15 mg in morning, 5 mg in early afternoon) for less severe cases 1

2. Fluid resuscitation

   • IV normal saline for volume depletion and to correct hyponatremia 2

3. Monitor vital signs and electrolytes frequently

Transitional Management

After initial stabilization:

1. Taper stress-dose steroids over 5-7 days to maintenance doses 2

2. Transition to maintenance therapy:

   • Hydrocortisone 15-20 mg daily in divided doses (10-15 mg in morning, 5 mg in early afternoon) 1
   • Alternatively, return to previous steroid with proper tapering schedule

3. Patient education on:

   • Stress dosing during illness (double or triple dose) 1
   • Emergency injectable hydrocortisone 1
   • Medical alert bracelet/ID 1

Long-term Follow-up

1. Test for HPA axis recovery after 3 months of maintenance therapy 2

   • Morning cortisol level
   • ACTH stimulation test if morning cortisol is indeterminate

2. Gradual tapering of steroids once HPA axis function returns

   • Reduce dose by no more than 2.5-5 mg every 1-2 weeks 2

3. Monitor for symptoms of adrenal insufficiency during tapering

Important Considerations

• Steroid dose at time of discontinuation is a significant predictor of adrenal insufficiency risk - higher doses lead to greater risk 5

• Duration of prior steroid therapy - Suppression can occur after just 2 weeks of therapy, but is almost universal after months of treatment 6

• Avoid starting thyroid hormone replacement before cortisol replacement in patients with multiple hormone deficiencies, as this can precipitate adrenal crisis 1

• AM cortisol in a patient on corticosteroids is not diagnostic as the measurement of therapeutic steroids in the assay for cortisol varies 2

• Even local steroid injections (intra-articular, epidural) can cause systemic absorption and HPA axis suppression 7

By following this approach, you can effectively manage the potentially life-threatening condition of adrenal insufficiency following abrupt steroid discontinuation while minimizing complications and supporting recovery of the HPA axis.