How to manage steroid-induced Cushing's syndrome?

Management of Steroid Abuse-Induced Cushing's Syndrome

The primary treatment for exogenous steroid-induced Cushing's syndrome is gradual tapering and discontinuation of the offending steroid medication, while providing appropriate adrenal axis support during withdrawal. 1

Diagnosis and Recognition

• Exogenous steroid-induced Cushing's syndrome presents with cushingoid facies, central obesity, muscle wasting, hypertension, hyperglycemia, hypokalemia, osteoporosis, and increased susceptibility to infections 1, 2
• Laboratory findings typically show suppressed endogenous cortisol production and ACTH levels due to negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis 1
• Evaluate morning cortisol and ACTH levels to confirm diagnosis and distinguish from other causes of Cushing's syndrome 3

Treatment Approach

1. Steroid Tapering Protocol

• Develop an individualized tapering schedule based on: 1

  • Duration of steroid use
  • Total cumulative dose
  • Underlying condition being treated

• For patients with mild symptoms (Grade 1): 3

  • Reduce maintenance dosing gradually
  • Monitor for symptoms of iatrogenic Cushing's syndrome (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia)

• For patients with moderate symptoms (Grade 2): 3

  • Consider temporary increase to 2-3 times maintenance dose (e.g., hydrocortisone 30-50 mg total daily dose or prednisone 20 mg daily) to manage acute symptoms
  • Decrease to maintenance doses after symptoms improve (typically after 2 days)

• For patients with severe symptoms (Grade 3-4): 3

  • May require inpatient management
  • Provide IV hydrocortisone 50-100 mg every 6-8 hours initially
  • Taper to oral maintenance doses over 5-7 days

2. Monitoring During Tapering

• Monitor for signs of adrenal insufficiency during tapering: 1

  • Fatigue, weakness, hypotension, hypoglycemia
  • Morning cortisol levels to assess recovery of HPA axis function

• Provide stress-dose steroids during periods of illness, surgery, or significant stress 1

• Recovery time for normal HPA activity varies from weeks to months depending on dose and duration of treatment 1, 4

3. Management of Complications

• Hypertension: Appropriate antihypertensive therapy 1
• Hyperglycemia/diabetes: Blood glucose monitoring and management 1
• Hypokalemia: Potassium supplementation as needed 1
• Osteoporosis: 3, 1
  • Calcium supplementation (1200-1500 mg/day)
  • Vitamin D supplementation
  • Bisphosphonates for prevention/treatment of bone loss
  • DEXA scan to assess bone density

Special Considerations

• In cases of severe hypercortisolism with life-threatening complications, consider temporary use of adrenostatic agents (ketoconazole, metyrapone, osilodrostat, or mitotane) while tapering 1, 5

• For topical steroid-induced Cushing's syndrome: 6, 7

  • Discontinue the topical steroid
  • Switch to less potent alternatives if needed for underlying condition
  • Avoid occlusive dressings
  • Educate patient on proper application and risks of overuse

• Steroid withdrawal syndrome may develop despite acceptable cortisol levels: 4

  • Symptoms mimic adrenal insufficiency
  • May require temporary increase in glucocorticoid replacement
  • Self-limiting condition (median duration 10 months)

Prevention Strategies

• Use the lowest effective dose of steroids for the shortest duration possible 1
• Consider steroid-sparing agents when appropriate 1
• Patients should carry medical alert identification during and after tapering 1
• Educate patients about signs of adrenal insufficiency and when to seek medical attention 3