Adrenal Suppression and Steroid Withdrawal Syndrome

What dose of hydrocortisone per day should prompt a patient to be put on a scheme of gradual withdrawal?

What symptoms are part of the withdrawal syndrome associated with stopping exogenous steroids?

What is the potential consequence if a patient on corticosteroid therapy discontinues the steroid during an infection?

Why is administration of ACTH during withdrawal not recommended?

Why might patients on corticosteroid therapy need protection with a corticosteroid if a stressful situation develops up to one year after withdrawal?

What is a measure to minimize HPA axis suppression when administering steroids?

Why are longer acting steroids like dexamethasone not suitable for alternate-day therapy?

What is a drawback of alternate-day therapy for some steroid dependent patients?

Why does giving a moderate dose of a short-acting steroid at 48 hour intervals not cause HPA suppression?

What type of preparations of a steroid with poor systemic availability can be used if appropriate?

Corticosteroid Therapy and Withdrawal

A daily dose of hydrocortisone above 7.5mg should prompt a patient to be put on a scheme of gradual withdrawal to prevent withdrawal syndrome.

Withdrawal Syndrome

Symptoms of withdrawal syndrome associated with stopping exogenous steroids include:
- Muscle weakness
- Fatigue
- Joint pain
- Arthritis
- Weight loss
- Fever
- Hypotension
- Hypoglycemia

Consequences of Discontinuing Corticosteroid Therapy

If a patient on corticosteroid therapy discontinues the steroid during an infection, it can lead to a flare-up of the infection, as the body's natural cortisol response is suppressed.

ACTH Administration During Withdrawal

Administration of ACTH (Adrenocorticotropic Hormone) during withdrawal is not recommended because it can stimulate the adrenal glands to produce more cortisol, making it difficult to assess the patient's natural cortisol response.

Stressful Situations After Withdrawal

Patients on corticosteroid therapy may need protection with a corticosteroid even up to one year after withdrawal if a stressful situation develops, as their HPA axis may not be fully recovered.

Minimizing HPA Axis Suppression

One measure to minimize HPA axis suppression when administering steroids is to use alternate-day therapy, which can help preserve the body's natural cortisol response.

Alternate-Day Therapy

Longer acting steroids like dexamethasone are not suitable for alternate-day therapy because they can suppress the HPA axis even on the "off" day.
A drawback of alternate-day therapy for some steroid-dependent patients is that it may not provide adequate control of symptoms.

HPA Suppression and Steroid Administration

Giving a moderate dose of a short-acting steroid at 48-hour intervals does not cause HPA suppression because it allows the body's natural cortisol response to recover between doses.

Steroid Preparations

Preparations of a steroid with poor systemic availability, such as topical or inhaled steroids, can be used if appropriate to minimize HPA axis suppression.

This quiz covers the suppression of the hypothalamo-pituitary-adrenal (HPA) axis due to exogenous steroid therapy, including the atrophy of the adrenal cortex and the precipitated withdrawal syndrome. It also examines the potential manifestation of acute adrenal insufficiency during stress in affected patients.