European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Abstract

Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.

Keywords: adrenal crisis; adrenal insufficiency; glucocorticoid withdrawal; glucocorticoids; steroids; substitution therapy.

Figure 1.

Schematic representation of HPA axis recovery following discontinuation of supraphysiologic glucocorticoid therapy (adapted from: Prete and Bancos 2021 (58)).

Figure 2.

Proposed approach to systemic glucocorticoid discontinuation.

Figure 3.

Management of patients at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency with suspected adrenal crisis or during exposure to stress.