Would adrenal insufficiency be a consideration for shock in a patient with a history of cancer and checkpoint inhibitor-induced colitis who received intravenous (IV) methylprednisolone (a corticosteroid) 20 mg that morning?

Adrenal Insufficiency is LESS LIKELY as the Cause of Shock in This Patient

A single dose of IV methylprednisolone 20 mg that morning provides sufficient glucocorticoid coverage to prevent adrenal crisis for at least 12-24 hours, making adrenal insufficiency an unlikely explanation for acute shock developing the same day. 1, 2

Why Adrenal Insufficiency is Less Likely

Adequate Glucocorticoid Coverage

• Methylprednisolone 20 mg IV is equivalent to approximately 100 mg of hydrocortisone, which represents a full stress-dose bolus used to treat acute adrenal crisis 1, 2
• The FDA label for methylprednisolone explicitly states that "increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy who are subjected to any unusual stress," confirming that the morning dose should provide adequate coverage 2
• Even patients with confirmed adrenal insufficiency receiving stress-dose steroids (hydrocortisone 100 mg IV) show rapid hemodynamic stabilization within hours, not immediate deterioration 1, 3

Timing Considerations

• Adrenal crisis from steroid withdrawal typically occurs hours to days after complete cessation, not while therapeutic levels remain present 1
• The development of shock after stopping methylprednisolone represents a "preventable iatrogenic adrenal crisis," but this patient received the medication that same morning 1
• Drug-induced secondary adrenal insufficiency may persist for months after discontinuation, but the risk manifests during periods without any corticosteroid coverage 2

When Adrenal Insufficiency WOULD Be a Consideration

High-Risk Scenarios That Don't Apply Here

• If the patient had NOT received any corticosteroids that morning, then adrenal insufficiency would be the primary consideration, especially given the history of checkpoint inhibitor-induced colitis requiring steroids 1, 4
• If shock developed 24-48 hours after the last methylprednisolone dose, adrenal crisis would move higher on the differential 1
• If the patient had been on chronic high-dose steroids (≥20 mg prednisone equivalent daily for ≥3 weeks) and then abruptly stopped, adrenal crisis would be highly likely 5, 6

The Underlying Risk Remains

• This patient DOES have underlying adrenal insufficiency risk from checkpoint inhibitor therapy and prior steroid use for colitis 7, 1, 4
• Morning cortisol <6 μg/dL with shock would be diagnostic of adrenal insufficiency, but cannot be accurately interpreted while on exogenous steroids 1, 5
• Patients on corticosteroids will have low morning cortisol as a result of iatrogenic secondary adrenal insufficiency—this is expected and not diagnostic 7, 5

Alternative Explanations for Shock Should Be Prioritized

More Likely Causes in This Context

• Septic shock from infection (given history of colitis and immunosuppression from checkpoint inhibitors and steroids) 7, 8
• Cardiogenic shock (corticosteroids can cause left ventricular free wall rupture post-MI and cardiac complications) 2
• Hypovolemic shock from gastrointestinal bleeding or dehydration related to colitis 7
• Distributive shock from other causes (anaphylaxis, neurogenic) 9

Critical Pitfall to Avoid

• Do not delay evaluation and treatment of other shock etiologies by assuming adrenal insufficiency is the cause when the patient received adequate corticosteroid coverage that morning 1, 5
• However, if shock remains refractory to fluids and vasopressors without clear causation, empiric stress-dose hydrocortisone (100 mg IV bolus) should still be administered as both diagnostic and therapeutic 1, 9, 3

Practical Management Approach

Immediate Actions

• Treat the shock according to standard protocols: fluid resuscitation, vasopressor support, and identification of the underlying cause 1, 9
• If hypotension remains refractory despite adequate resuscitation, consider empiric hydrocortisone 100 mg IV bolus even though adrenal crisis is less likely 1, 9, 3
• The methylprednisolone dose received that morning does NOT preclude giving additional stress-dose steroids if clinically indicated 1, 2

Diagnostic Considerations

• Morning cortisol and ACTH measurements are not interpretable while the patient is on exogenous steroids 7, 5
• Laboratory confirmation of adrenal insufficiency should not be attempted until corticosteroid treatment is ready to be discontinued and sufficient washout time has elapsed 5
• Focus diagnostic efforts on identifying sepsis, cardiac complications, bleeding, or other reversible causes of shock 9, 8

Long-Term Follow-Up

• After recovery from acute illness, this patient requires formal evaluation for checkpoint inhibitor-induced adrenal insufficiency with morning cortisol, ACTH, and potentially cosyntropin stimulation testing 7, 1, 4
• If adrenal insufficiency is confirmed, lifelong glucocorticoid replacement, patient education on stress dosing, medical alert bracelet, and emergency injectable hydrocortisone kit are mandatory 1, 4, 6
• Endocrine consultation is required for all patients with checkpoint inhibitor-induced adrenal insufficiency 7, 1, 4