Assessing Ongoing Need for Steroid Therapy in Presumed Central Adrenal Insufficiency

Key Principles

The American College of Oncology recommends that laboratory confirmation of adrenal insufficiency cannot be performed while a patient is actively taking corticosteroids for other conditions, and testing must be deferred until the patient is ready to discontinue corticosteroid treatment, at which point endocrinology consultation for a recovery and weaning protocol using hydrocortisone is essential 1, 2
The American College of Oncology states that you cannot accurately test for central adrenal insufficiency while the patient is on exogenous corticosteroids, as the exogenous steroids suppress the hypothalamic-pituitary-adrenal (HPA) axis and interfere with interpretation of results 1, 2

The patient must be clinically ready to discontinue corticosteroid therapy, and for patients on long-term glucocorticoid exposure, endocrinology consultation is required for establishing a recovery and weaning protocol 1, 2
Testing should be deferred until treatment with corticosteroids is ready to be discontinued, and the patient should be tapered to physiologic replacement doses of hydrocortisone (typically 15-25 mg daily in divided doses) 1, 2, 3

The American College of Oncology recommends gradually tapering the patient to physiologic replacement doses of hydrocortisone, which mimics natural cortisol rhythm and allows assessment of the HPA axis 1, 2, 3
After discontinuing glucocorticoids, a low-dose ACTH stimulation test (cosyntropin challenge) should be performed to definitively assess HPA axis function 4

Patients must be educated on stress dosing (doubling doses during illness) and provided with emergency injectable steroids, and a medical alert bracelet for adrenal insufficiency is mandatory to trigger stress-dose corticosteroids by emergency medical services 1, 2, 3
Patients should be warned about signs of adrenal crisis, including severe weakness, confusion, abdominal pain, and hypotension 3

For patients with checkpoint inhibitor-induced hypophysitis, periodic assessment every 3 months in the first year, then every 6 months thereafter with clinical monitoring and repeat hormone levels (morning cortisol and ACTH and/or low-dose cosyntropin stimulation test) is recommended to assess recovery 4
The American Society of Clinical Oncology recommends that patients on ongoing oral glucocorticoid treatment or initially after withdrawal have adrenal insufficiency, and higher maximum glucocorticoid doses significantly predict development of adrenal suppression 4