Signs and Symptoms of Worsening Adrenal Insufficiency When Reducing Glucocorticoid Dose
When reducing glucocorticoid dose from 7.5 mg AM/5 mg PM to 5 mg twice daily, patients should be closely monitored for symptoms of worsening adrenal insufficiency including fatigue, lethargy, nausea, poor appetite, weight loss, hyperpigmentation, hypotension, and electrolyte disturbances. 1
Key Warning Signs of Adrenal Insufficiency
Early/Common Symptoms
- Fatigue and lethargy
- Nausea and poor appetite
- Morning symptoms (lack of appetite, nausea, vomiting)
- Weight loss
- Increased or uneven skin pigmentation
- Dips in energy during the day
- Mental concentration difficulties
- Daytime somnolence
More Severe Signs
- Hypotension (especially postural)
- Salt craving
- Abdominal pain
- Vomiting
- Dizziness upon standing
- Hypoglycemia
- Electrolyte disturbances (hyponatremia, hyperkalemia)
Risk Assessment for This Dose Reduction
The proposed dose reduction from 7.5 mg AM/5 mg PM (12.5 mg total) to 5 mg twice daily (10 mg total) represents:
- A decrease in total daily dose (from 12.5 mg to 10 mg)
- A change in the diurnal pattern of administration
This change carries risk because:
- Any patient receiving more than 7.5 mg of prednisolone equivalent daily for more than 3 weeks may have hypothalamic-pituitary-adrenal (HPA) axis suppression 1
- The morning dose is being reduced from 7.5 mg to 5 mg, which may not provide adequate peak cortisol levels to match natural circadian rhythm
- Approximately 50% of patients on chronic glucocorticoid therapy develop adrenal insufficiency 2
Monitoring Recommendations
Clinical Assessment
Monitor for the following during and after dose reduction:
- Weight changes (weight loss suggests under-replacement)
- Blood pressure (especially postural drops)
- General energy levels and "get up and go" feeling
- Sleep patterns and insomnia
- Mental concentration
- Changes in skin pigmentation
Timing Considerations
- Morning symptoms are particularly important to monitor as they often indicate inadequate replacement
- Note any "low points" or energy dips during the day 1
Laboratory Monitoring
- Serum electrolytes (sodium, potassium)
- Blood glucose
- Note that plasma ACTH and serum cortisol are not useful parameters for glucocorticoid dose adjustment 1
Special Considerations for This Patient
Since the patient's primary concerns are weight gain and bloating:
- These are known side effects of glucocorticoid therapy 1
- However, reducing the dose too quickly may lead to adrenal insufficiency symptoms that could be more severe than the current side effects
- Weight gain occurs in 0-63% of patients on chronic medium-dose glucocorticoids 1
Practical Approach to Dose Reduction
Consider a more gradual reduction:
- First reduce the evening dose from 5 mg to 2.5 mg for 2-4 weeks
- Then reduce the morning dose from 7.5 mg to 5 mg
- Finally adjust to 5 mg twice daily if tolerated
Alternatively, if proceeding directly to 5 mg twice daily:
- Ensure the first dose is taken immediately upon waking
- Consider taking the second dose earlier (around noon) rather than in the evening to better mimic natural cortisol rhythm 1
Educate the patient about:
- Symptoms requiring immediate medical attention
- Stress dose requirements during illness
- Carrying medical identification indicating adrenal insufficiency
Adrenal Crisis Warning Signs Requiring Immediate Attention
Instruct the patient to seek immediate medical attention if experiencing:
- Severe weakness, fatigue or confusion
- Persistent vomiting or diarrhea
- Hypotension (especially with dizziness upon standing)
- Severe abdominal, back or leg pain
- Loss of consciousness
These symptoms may indicate adrenal crisis, which is life-threatening and requires immediate treatment with parenteral glucocorticoids 1.