Symptoms of Post-Steroid Adrenal Insufficiency
Post-steroid adrenal insufficiency typically presents with fatigue (50%-95%), nausea and vomiting (20%-62%), anorexia, weight loss (43%-73%), hypotension, hyponatremia, hyperkalemia, and can progress to life-threatening adrenal crisis if untreated. 1
Clinical Presentation
Common Symptoms
- Fatigue and weakness
- Nausea and vomiting
- Anorexia and weight loss
- Dizziness or lightheadedness (especially when standing)
- Abdominal pain
- Mood changes including depression, irritability, and anxiety
- Hypoglycemia
Physical Findings
- Hypotension (especially orthostatic)
- Electrolyte abnormalities:
- Hyponatremia (low sodium)
- Hyperkalemia (high potassium) - more common in primary adrenal insufficiency 2
- Hyperpigmentation (only in primary adrenal insufficiency, not in post-steroid secondary adrenal insufficiency) 2
Pathophysiology
Glucocorticoid-induced adrenal insufficiency occurs when exogenous glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis 3. This suppression can persist for months after discontinuation of steroid therapy 4. The condition is the most prevalent form of adrenal insufficiency and is often underdiagnosed, with studies showing that while approximately 50% of patients on oral glucocorticoids develop adrenal insufficiency, less than 1% have adrenal testing recorded 3.
Diagnosis
Laboratory Findings
- Low morning cortisol levels (often <5 μg/dL)
- Low or low-normal ACTH levels (distinguishing from primary adrenal insufficiency which has high ACTH)
- Failed response to ACTH stimulation test (peak cortisol <18-20 μg/dL) 2, 1
Risk Factors
- Higher doses of glucocorticoids
- Longer duration of therapy
- Abrupt discontinuation rather than gradual tapering
- Even local steroid injections (intra-articular, epidural) can cause systemic absorption and HPA axis suppression 5
Adrenal Crisis
Adrenal crisis is a life-threatening emergency that can occur in patients with adrenal insufficiency, especially during times of stress. Symptoms include:
- Severe hypotension or shock
- Severe abdominal pain, nausea, and vomiting
- Altered mental status
- Fever
- Severe weakness
- Hypoglycemia
This requires immediate treatment with IV hydrocortisone 100 mg followed by normal saline infusion 2.
Treatment Approach
Replacement Therapy:
Stress Dosing Protocol:
- Minor illness/stress: Double or triple the usual daily dose
- Moderate stress: Hydrocortisone 50-75 mg/day in divided doses
- Severe stress: Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day 2
Patient Education:
Recovery and Monitoring
Most cases of post-steroid adrenal insufficiency resolve over time as the HPA axis recovers, but this can take months after discontinuation of steroids 4. Some cases may resolve within weeks 5, while others may take longer depending on the duration and dose of previous steroid therapy.
Regular monitoring should include:
- Assessment of symptoms
- Blood pressure measurements
- Serum electrolyte testing
- Morning cortisol levels to assess recovery of the HPA axis 2
Common Pitfalls
Failure to recognize symptoms: The nonspecific nature of symptoms often leads to delayed diagnosis, especially during acute hospital admissions 3.
Inadequate stress dosing: Patients may not understand the importance of increasing their glucocorticoid dose during illness or stress, leading to adrenal crisis 3.
Abrupt discontinuation: Drug-induced adrenal insufficiency should be minimized by gradual reduction of steroid dosage 4.
Overlooking adrenal insufficiency from local steroid injections: Even intra-articular or other local steroid injections can cause systemic absorption and HPA axis suppression 5.