What is the workup for steroid-induced adrenal insufficiency (AI)?

From the Guidelines

To evaluate steroid-induced adrenal insufficiency, a comprehensive workup should include an early morning cortisol level test, followed by an ACTH stimulation test if necessary, and consideration of the patient's clinical presentation and medical history, as recommended by the most recent guidelines 1. The workup for steroid-induced adrenal insufficiency involves several key steps:

• Perform an early morning (8 AM) cortisol level test to assess adrenal function
• If the result is less than 3 mcg/dL, adrenal insufficiency is likely; if greater than 15 mcg/dL, it's unlikely
• For intermediate values (3-15 mcg/dL), proceed with an ACTH stimulation test to confirm the diagnosis
• Consider the patient's clinical presentation, medical history, and risk factors, such as higher steroid doses, longer duration of therapy, and more potent steroids
• Educate patients on stress dosing, emergency injectables, and the importance of a medical alert bracelet or necklace, as emphasized in the guidelines 1, 2, 3 Some key points to consider in the workup and management of steroid-induced adrenal insufficiency include:
• The importance of early endocrinology consultation for patients with suspected adrenal insufficiency, as recommended in the guidelines 1
• The need for education on stress dosing and emergency procedures, such as the use of hydrocortisone self-administration kits, as highlighted in the guidelines 3
• The importance of collaboration with the patient's endocrinologist when planning scheduled surgery or caring for postoperative cases, as emphasized in the guidelines 3
• The need for careful consideration of the patient's individual risk factors and medical history when developing a treatment plan, as recommended in the guidelines 1, 2, 3

From the FDA Drug Label

PRECAUTIONS General Precautions Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted The workup for steroid-induced adrenal insufficiency (AI) is not directly addressed in the label, but it can be inferred that:

• Gradual reduction of dosage may help minimize the risk of AI
• Hormone therapy should be reinstituted in situations of stress after discontinuation of therapy
• Monitoring for signs of AI may be necessary for months after discontinuation of therapy 4 Key points to consider:
• Stress may trigger the need for hormone therapy
• Gradual dosage reduction is recommended to minimize the risk of AI
• Hormone therapy may be necessary to manage AI

From the Research

Diagnosis of Steroid-Induced Adrenal Insufficiency

The diagnosis of steroid-induced adrenal insufficiency (AI) is made with a stimulation test, such as the ACTH test 5. The following are key points to consider in the workup for steroid-induced AI:

• The ACTH test is used to diagnose AI, but the test may not be sensitive in all cases, particularly in patients with acute spinal cord injury 6.
• The 250 µg cosyntropin stimulation test may not be the most sensitive test to diagnose AI in acute spinal cord injury, and a 1 µg cosyntropin stimulation test may be more sensitive 6.
• The corticotropin-releasing hormone (CRH) stimulation test may be useful in differentiating between hypothalamic and pituitary causes of adrenal insufficiency 7.
• Plasma cortisol levels and ACTH responses to CRH can help diagnose AI, but the results must be interpreted with caution, particularly in critically ill patients 8.

Clinical Presentation and Prevalence

The clinical presentation of steroid-induced AI can be non-specific and may include symptoms such as hypotension, weakness, and fatigue 5, 6. The prevalence of AI associated with inhaled corticosteroids is estimated to be low, but the likelihood of under-diagnosis is high 9. Key points to consider include:

• The prevalence of AI associated with inhaled corticosteroids is estimated to be low, but the risk of under-diagnosis is high 9.
• High doses of inhaled corticosteroids can induce systemic adverse effects, including AI 9.
• The clinical presentation of AI can be non-specific and may be easily confused with other common sequelae of underlying conditions 6.

Treatment and Management

The treatment of steroid-induced AI typically involves the use of corticosteroids, such as hydrocortisone 5, 8. Key points to consider include:

• Hydrocortisone should be the choice of steroid for most patients with relative AI 8.
• Fludrocortisone can be added on a case-by-case basis in refractory shock 8.
• The use of supplemental steroid therapy in septic shock patients can result in immediate hemodynamic benefits, but the mortality benefits are controversial 8.