Adrenal insufficiency Glucocorticoid withdrawal syndrome
Symptoms anorexia, fatigue, nausea, vomiting, dyspnea, fever, arthralgia, myalgia, and orthostatic hypotension, dizziness, fainting, circulatory collapse anorexia, nausea, emesis, weight loss, fatigue, myalgias, arthralgias, weakness, headache, abdominal pain, lethargy, postural hypotension, fever, skin desquamation, tachycardia, emotional lability, delirium, psychotic states
Steroid dosage Symptomatic below physiological doses (prednisolone 7.5mg or equivalent) Symptoms can occur at supraphysiological doses of glucocorticoids
HPA testing
Cortisol insufficiency 9am cortisol <100nmol/L and/or Peak cortisol after synacthen stimulation <550nmol/L Normal HPA function 9am cortisol >450nmol/L and/or Peak cortisol after synacthen stimulation >550nmol/L
Risk of adrenal crisis Yes No
Management
Reduce glucocorticoids to physiological dose Long term replacement with hydrocortisone 15-20 mg/ day or prednisolone 4-5 mg/day Increase glucocorticoids during intercurrent illness Very slow wean over the long term to allow HPA axis recovery Reduce glucocorticoids to the lowest possible dose that controls symptoms Then withdraw very slowly over months No need to increase glucocorticoids during intercurrent illness Consider retesting HPA axis if glucocorticoid wean is very prolonged and difficult