Corticosteroid-induced adrenal insufficiency

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.

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.

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.

Risk factors for corticosteroid-induced adrenal insufficiency include prolonged high-dose corticosteroid therapy, high-dose ICSs, and abrupt cessation of corticosteroids after prolonged use. Other risk factors include underlying diseases, age, and the number of treating clinicians involved in the care of the patient, as these factors may increase the likelihood of polypharmacy and the risk of iatrogenic events.

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.

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.