In a patient on chronic prednisolone 7 mg daily, increased to 14 mg for pneumonia and tapered to 10 mg before a second pneumonia, how likely is the failure to give stress‑dose steroids (doubling the dose) to have caused the adrenal crisis?

Likelihood of Failure to Give Stress-Dose Steroids Contributing to Adrenal Crisis

The failure to double the prednisolone dose during the second pneumonia episode very likely contributed to the adrenal crisis, as this patient had documented iatrogenic adrenal suppression from chronic prednisolone therapy and faced a major physiological stressor (pneumonia) without adequate glucocorticoid coverage. 1

Risk Assessment in This Clinical Scenario

Established Adrenal Suppression

• This patient was on chronic prednisolone therapy at doses ranging from 7-14 mg daily for an extended period, which definitively causes HPA axis suppression 1
• Any prednisolone dose ≥5 mg daily for longer than 1 month represents an adrenal suppressive dose in a significant proportion of adults 1
• Data from short synacthen tests show that approximately one-third to one-half of patients receiving 5-20 mg prednisolone daily fail to achieve adequate cortisol response, indicating inadequate adrenal reserve 1

Pneumonia as a Major Physiological Stressor

• Infections, particularly respiratory infections with fever, are among the most common precipitants of adrenal crisis in patients with adrenal insufficiency 2, 3
• Approximately half of patients who experience adrenal crisis report infections (especially gastroenteritis or fever) as the precipitating factor 1
• The patient had already required stress-dose steroids (doubling from 7 mg to 14 mg) during the first pneumonia episode, demonstrating both the severity of the physiological stress and appropriate clinical response 1

The Critical Omission

• The provider's recommendation to double the steroids during the second pneumonia was medically appropriate and guideline-concordant 1, 2
• Failure to increase glucocorticoid dosing during physiological stress in patients with suppressed HPA axis is a recognized cause of adrenal crisis 2, 3
• The incidence of adrenal crisis in patients with adrenal insufficiency is 6-8 cases per 100 patient-years, with infections being the leading trigger 2, 4

Mechanistic Explanation

Relative Adrenal Insufficiency

• Even though the patient was on 10 mg prednisolone (higher than her baseline 7 mg), this dose was insufficient for the stress of acute pneumonia 1
• Adrenal crisis symptoms and signs can occur in physiologically stressed patients even while plasma cortisol levels appear normal or elevated—this is the concept of "relative adrenal insufficiency" 1
• The body's cortisol requirement during severe infection can increase 10-15 fold above baseline physiological needs 5

Iatrogenic Adrenal Insufficiency Context

• Iatrogenic (tertiary) adrenal insufficiency from chronic glucocorticoid therapy is the most common form, affecting approximately 7 per 1,000 patients on long-term corticosteroids—roughly 100 times more prevalent than primary adrenal insufficiency 3
• Patients with glucocorticoid-induced adrenal insufficiency remain at risk of adrenal crisis during any physical stress until the HPA axis fully recovers, which typically takes months after glucocorticoid withdrawal 2, 6

Clinical Evidence Supporting High Likelihood

Guideline Recommendations

• UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology explicitly state that "it is vital that physiological replacement therapy is not interrupted, and that the daily dose is increased at times of physiological stress" 1
• These same guidelines recommend that given the risks of inadequate glucocorticoid response and lack of long-term harm from short-term supplementation, "if in doubt about the need for glucocorticoids they should be given" 1

Mortality Risk

• The overall mortality rate in patients with adrenal insufficiency is significantly elevated, with a risk ratio of 2.19 for men and 2.86 for women 2, 4
• Two patients died during adrenal crisis in a prospective 2-year follow-up study of 423 patients with adrenal insufficiency 1

Common Pitfalls That Occurred Here

Medication Errors During Hospitalization

• Errors in medication administration, including omission of doses or inadequate dosing during hospitalizations, are recognized precipitants of adrenal crisis 3
• Ward nursing staff may dismiss observations about warning signs of glucocorticoid under-replacement during illness 1

Underrecognition of Risk

• More than 70% of glucocorticoid-induced adrenal insufficiency cases are identified during acute hospital admissions, where the diagnosis is easily missed because symptoms are nonspecific 6
• During ongoing glucocorticoid treatment, approximately 50% of patients have adrenal insufficiency, but outside clinical studies, ≤1% have adrenal testing recorded 6

Conclusion on Likelihood

The failure to provide stress-dose steroids (doubling the prednisolone) during the second pneumonia episode had a very high likelihood of contributing to the adrenal crisis. This patient had all the key risk factors: documented chronic glucocorticoid therapy causing HPA suppression, a major physiological stressor (pneumonia), and failure to increase glucocorticoid dosing despite appropriate medical recommendation. The combination of these factors creates a textbook scenario for precipitating adrenal crisis in a patient with iatrogenic adrenal insufficiency. 1, 2, 3