Should a patient with secondary adrenal insufficiency due to ongoing bilateral steroid (corticosteroid) hip injections continue hydrocortisone (cortisol replacement therapy)?

Management of Secondary Adrenal Insufficiency from Ongoing Bilateral Steroid Hip Injections

Direct Answer

Yes, the patient should be placed on hydrocortisone replacement therapy for secondary adrenal insufficiency caused by ongoing bilateral steroid hip injections, as the exogenous corticosteroids from the injections have suppressed the hypothalamic-pituitary-adrenal (HPA) axis, creating a state of cortisol deficiency that requires physiologic glucocorticoid replacement until the axis recovers. 1, 2

Understanding the Clinical Situation

Why This Occurs

• Exogenous corticosteroids from repeated hip injections suppress the HPA axis, preventing the pituitary from producing ACTH and subsequently causing the adrenal glands to stop producing cortisol 2, 3
• This creates secondary (or tertiary) adrenal insufficiency, where the problem lies in the pituitary/hypothalamus, not the adrenal glands themselves 1, 2
• The suppression persists even while receiving ongoing injections, because the intermittent dosing from injections does not provide consistent physiologic cortisol coverage throughout each day 4, 2

Critical Distinction from Primary Adrenal Insufficiency

• Secondary adrenal insufficiency does NOT require mineralocorticoid (fludrocortisone) replacement, unlike primary adrenal insufficiency, because the adrenal glands can still produce aldosterone when stimulated by the renin-angiotensin system 1, 2
• The patient will lack aldosterone deficiency symptoms (severe salt craving, marked hyperkalemia) that characterize primary disease 2, 3

Treatment Protocol

Immediate Hydrocortisone Replacement

• Start hydrocortisone 15-25 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, or 15 mg morning, 5-10 mg afternoon) 4, 2, 5
• Do NOT use the corticosteroid from hip injections as replacement therapy, as these are typically long-acting depot preparations (triamcinolone, methylprednisolone) that provide unpredictable absorption and cannot be adjusted for stress dosing 2
• Hydrocortisone is preferred over prednisone because it is short-acting and more closely mimics physiologic cortisol secretion 1, 2

Why Replacement is Essential Despite Ongoing Injections

• The hip injections provide supraphysiologic doses intermittently but leave gaps in cortisol coverage, particularly during physiologic stress when the body cannot mount its own cortisol response 4, 2
• Patients remain at risk for adrenal crisis during any physical stress (infection, surgery, trauma, severe illness) because the suppressed HPA axis cannot respond appropriately 1, 6, 2
• The mortality rate is significantly increased (2.19-fold for men, 2.86-fold for women) in untreated adrenal insufficiency 1

Critical Patient Education Requirements

Stress Dosing Instructions

• Double the usual hydrocortisone dose during minor illness (fever, gastroenteritis, dental procedures) 1, 6, 3
• Triple the dose or use parenteral hydrocortisone for severe illness, particularly if vomiting prevents oral intake 1, 6, 3
• Provide emergency injectable hydrocortisone 100 mg IM with training on self-administration or family member administration 1, 2, 3

Warning Signs of Adrenal Crisis

• Persistent vomiting or diarrhea (cannot absorb oral medication when needed most) 1, 6
• Severe hypotension, particularly orthostatic hypotension (early warning sign) 1, 6
• Profound fatigue, confusion, or altered mental status 6, 2, 3
• Unexplained abdominal pain, nausea, muscle pain 6, 3

Medical Alert Identification

• All patients must wear medical alert jewelry or carry a steroid emergency card to trigger stress-dose corticosteroids by emergency medical personnel 1, 3

Planning for HPA Axis Recovery

When to Test for Recovery

• Test HPA axis function 3 months after discontinuing the hip injections, not while still receiving them 7, 1
• Use morning cortisol (drawn at 8 AM) or ACTH stimulation testing to assess recovery 1, 2
• Hydrocortisone must be held for 24 hours before testing, and other corticosteroids for longer periods, to avoid false results 7, 1

Recovery Timeline

• HPA axis recovery typically takes months after stopping exogenous corticosteroids, not weeks 1, 4
• Do NOT assume recovery after only one week off steroids—this is a dangerous assumption 1
• Patients remain at risk for adrenal crisis during the entire recovery period until testing confirms adequate endogenous cortisol production 1, 8

Common Pitfalls to Avoid

Do Not Delay Treatment

• Never wait for diagnostic confirmation before starting hydrocortisone if clinical suspicion exists (fatigue, orthostatic hypotension, weight loss, hyponatremia) 6, 2
• Draw morning cortisol and ACTH before starting treatment if possible, but do not delay therapy waiting for results 6, 2

Do Not Confuse with Primary Adrenal Insufficiency

• Do NOT add fludrocortisone unless testing confirms primary adrenal insufficiency (elevated ACTH with low cortisol) 1, 2
• Absence of hyperpigmentation and severe salt craving supports secondary rather than primary disease 2, 3

Do Not Abruptly Stop Hydrocortisone

• Gradual taper is required when discontinuing, and only after confirming HPA axis recovery with testing 1, 4
• Abrupt discontinuation can precipitate life-threatening adrenal crisis 4, 8

Do Not Assume Adequate Coverage from Hip Injections Alone

• Even ongoing hip injections do not provide reliable physiologic cortisol replacement throughout each day or during stress 4, 2
• The depot formulations used for joint injections are not designed for HPA axis replacement 2

Monitoring During Treatment

Clinical Parameters

• Monitor blood pressure in both supine and standing positions to detect orthostatic hypotension (early warning sign of inadequate replacement) 1, 6
• Assess for return of normal energy, stable weight, and resolution of symptoms as indicators of adequate dosing 1, 2

Laboratory Monitoring

• Check serum sodium and potassium to evaluate for electrolyte abnormalities (hyponatremia is present in 90% of adrenal crises) 6
• Monitor blood glucose, particularly in patients with diabetes or during illness 6, 2

Dose Adjustments

• Increase hydrocortisone dose during any physiologic stress (surgery, infection, trauma) to prevent crisis 1, 6, 4
• The lowest effective dose should be used for maintenance, but never compromise safety by under-replacement 4