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Corticosteroid-induced adrenal insufficiency

What's new

Added 2024 ESE/ES guidelines for the diagnosis and management of corticosteroid-induced adrenal insufficiency.

Background

Overview

Definition
Corticosteroid-induced adrenal insufficiency, also known as iatrogenic adrenal insufficiency, is a condition arising from prolonged or high-dose exogenous glucocorticoid therapy, which suppresses the hypothalamic-pituitary-adrenal axis, leading to a decrease in endogenous cortisol production.
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Pathophysiology
The pathophysiology involves the inhibition of the release of corticotropin-releasing hormone and ACTH due to the exogenous corticosteroids, leading to reduced production and secretion of cortisol from the adrenal glands. When the exogenous corticosteroids are reduced or stopped, the suppressed hypothalamic-pituitary-adrenal axis may not immediately resume normal function, leading to a deficiency in cortisol, especially during times of stress.
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Epidemiology
Corticosteroid-induced adrenal insufficiency is the most common form of adrenal insufficiency in adult patients. Long-term oral corticosteroid use in the general population is estimated at 0.5-1.8%, with an absolute risk of 48.7% for developing adrenal insufficiency.
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Disease course
Clinically, patients with corticosteroid-induced adrenal insufficiency may present with non-specific symptoms such as fatigue, weakness, anorexia, nausea, vomiting, and hypotension. These symptoms can be exacerbated by stress or infection, potentially leading to an adrenal crisis characterized by severe hypotension and shock.
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Prognosis and risk of recurrence
The prognosis of corticosteroid-induced adrenal insufficiency is generally good with appropriate management, which involves gradual tapering of the exogenous corticosteroids and supportive care. If left untreated or if treatment is delayed, the condition can lead to severe complications, such as adrenal crisis.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of corticosteroid-induced adrenal insufficiency are prepared by our editorial team based on guidelines from the European Society of Endocrinology (ESE/ES 2024)....
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Diagnostic investigations

Indications for testing: as per ES/ESE 2024 guidelines, Be aware of the potential for corticosteroid-induced adrenal insufficiency in patients with any of the following:
current or recent use of non-oral corticosteroid formulations presenting with signs and symptoms indicative of adrenal insufficiency
simultaneous use of multiple corticosteroid formulations
use of high-dose inhaled or topical corticosteroids
use of inhaled or topical corticosteroids for > 1 year
have received intra-articular corticosteroid injections in the previous 2 months
receiving concurrent treatment with strong cytochrome P450 3A4 inhibitors.
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Medical management

Tapering corticosteroids: as per ES/ESE 2024 guidelines, Avoid referring patients on, or tapering off corticosteroids for non-endocrine conditions to an endocrinology specialist.
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More topics in this section

  • Corticosteroid therapy

Patient education

General counseling
As per ES/ESE 2024 guidelines:
Educate patients about various endocrine aspects of corticosteroid therapy when initiating treatment with corticosteroids.
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Ensure that patients on corticosteroid therapy have access to current, up-to-date, and appropriate information about different endocrine aspects of corticosteroid therapy.
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Follow-up and surveillance

Confirmation of recovery
As per ES/ESE 2024 guidelines:
Obtain morning serum cortisol testing if confirmation of hypothalamic-pituitary-adrenal axis recovery is desired. Recognize that the value of morning serum cortisol is a continuum, with higher values indicating a greater likelihood of hypothalamic-pituitary-adrenal axis recovery.
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Consider referring patients to an endocrinology specialist if they are attempting to discontinue glucocorticoids but have not shown recovery of the hypothalamic-pituitary-adrenal axis within 1 year while on a physiological daily dose equivalent.