What are the signs and symptoms of adrenal insufficiency during steroid (corticosteroid) taper?

From the Guidelines

Adrenal insufficiency during steroid taper presents with fatigue, weakness, dizziness, nausea, vomiting, abdominal pain, weight loss, and hypotension, and requires immediate medical attention if severe symptoms develop, as it can be life-threatening 1. The symptoms of adrenal insufficiency during steroid taper are caused by the suppression of the hypothalamic-pituitary-adrenal axis, preventing normal cortisol production when steroids are reduced.

Key Symptoms

• Fatigue
• Weakness
• Dizziness
• Nausea
• Vomiting
• Abdominal pain
• Weight loss
• Hypotension
• Salt cravings
• Hypoglycemia
• Mood changes, including depression or anxiety These symptoms can be managed by temporarily increasing the steroid dose to the previous well-tolerated level and slowing the taper, with education on stress dosing, emergency injections, and medical alert systems being crucial for patient safety 1.

Management

• Gradual tapering of steroids, reducing by 10-20% every 1-2 weeks for long-term users
• Morning dosing to mimic natural cortisol rhythm
• Education on symptoms to report and the importance of not stopping steroids abruptly
• Consideration of hydrocortisone replacement therapy, with doses titrated to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 1
• Fludrocortisone replacement may also be necessary, with starting doses of 0.05-0.1 mg/d and adjustments based on volume status, sodium level, and renin response 1 It is essential to prioritize patient education and monitoring during steroid tapering to prevent adrenal insufficiency and ensure prompt recognition and treatment of any symptoms that may arise, as the frequency of acute adrenal crises among patients with primary adrenal insufficiency is 6–8 per 100 patient-years 1.

From the FDA Drug Label

Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision As prolonged use may cause adrenal insufficiency and make patients dependent on corticosteroids, they should advise any medical attendants that they are taking corticosteroids and they should seek medical advice at once should they develop an acute illness including fever or other signs of infection Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy following large doses for prolonged periods; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.

The signs and symptoms of adrenal insufficiency with steroid taper include:

• Myalgia
• Arthralgia
• Malaise Adrenal insufficiency may be minimized by gradual reduction of dosage. Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision. In situations of stress, hormone therapy should be reinstituted 2, 2.

From the Research

Signs and Symptoms of Adrenal Insufficiency with Steroid Taper

• The signs and symptoms of adrenal insufficiency during steroid tapering can be life-threatening if left unrecognized and untreated 3
• Adrenal insufficiency can occur due to suppression of the endogenous hypothalamic-pituitary-adrenal (HPA) axis caused by glucocorticoid therapy, and abrupt discontinuation of glucocorticoids can predispose patients to features of glucocorticoid-induced adrenal insufficiency 4
• The practice of tapering glucocorticoid therapy allows for recovery of the HPA axis while minimizing the risk of a disease flare-up or symptoms of adrenal insufficiency 4
• Moderate-to-high dose glucocorticoid therapy may be tapered rapidly to near-physiological doses while watching for features of disease reactivation, and once close to the physiological dose, tapering is slower and at longer intervals to allow for recovery of the HPA axis 4
• Testing of HPA axis function using basal and/or stimulated serum cortisol can be used to diagnose adrenal insufficiency early on and to guide the decision to further taper and discontinue steroids 4, 3

Risk Factors for Adrenal Insufficiency

• Risk factors for adrenal suppression include doses greater than 5 to 7.5 mg of prednisone equivalent, duration of glucocorticoid use greater than 3 weeks, certain medications, and comorbidities 5
• The use of adrenal gland testing such as basal cortisol levels and adrenocorticotropic hormone stimulation tests can confirm adrenal suppression in patients 5

Prevention of Adrenal Crisis

• A structured schedule for the tapering of glucocorticoid treatment can reduce the risk of adrenal crisis and acute adrenal insufficiency 3
• Patients on exogenous steroids should be advised about the need for an appropriate increase in glucocorticoid doses during acute medical or surgical illness and should carry a steroid alert card to avoid adrenal crisis 4