Steroid-Induced Adrenal Insufficiency: Clinical Presentation and Management

Clinical Features

Morning nausea and lack of appetite are particularly common and may indicate under-replacement of glucocorticoids, according to the American College of Clinical Endocrinologists 1
Unexplained hypotension should raise immediate suspicion for adrenal insufficiency in any patient taking ≥20 mg/day prednisone or equivalent for at least 3 weeks, as recommended by the American College of Cardiology 1
Periumbilical abdominal pain may occur, particularly in acute presentations, as noted by the European Society of Endocrinology 2
Vomiting can be prominent and contributes to electrolyte disturbances, according to the American Gastroenterological Association 2

Hyponatremia is present in 90% of newly diagnosed adrenal insufficiency cases, making it a highly sensitive marker, as reported by the National Institute of Diabetes and Digestive and Kidney Diseases 1, 2
Hyperkalemia is notably ABSENT in steroid-induced adrenal insufficiency because aldosterone secretion is preserved, as stated by the American Heart Association 3, 2
Hypoglycemia may occur, particularly during acute illness or stress, according to the American Diabetes Association 3

Absence of hyperpigmentation (no elevated ACTH to stimulate melanocytes) is a key distinguishing feature from primary adrenal insufficiency, as noted by the Endocrine Society 4, 5
Preserved aldosterone function (no hyperkalemia or significant salt wasting) is another key distinguishing feature, according to the American College of Clinical Endocrinologists 2
Exogenous steroids including oral prednisolone, dexamethasone, and inhaled fluticasone confound interpretation of cortisol levels and must be considered when interpreting diagnostic tests, as recommended by the American Thoracic Society 3, 1

Treatment of suspected acute adrenal insufficiency should NEVER be delayed for diagnostic procedures if the patient is clinically unstable, as stated by the American College of Emergency Physicians 3, 6, 1
If unstable, give 100 mg IV hydrocortisone immediately without waiting for test results, according to the Society of Critical Care Medicine 1, 2
All patients require education on stress dosing, emergency injectable steroids, and should wear medical alert identification, as recommended by the American Academy of Pediatrics 4, 5