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Adrenal suppression

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
Last reviewed: 2 Aug 2025
Last updated: 02 May 2025

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • sudden cessation or rapid tapering of glucocorticoids
  • acute circulatory collapse with hypotension and tachycardia
Full details

Other diagnostic factors

  • lassitude and generalized constitutional symptoms
  • history of weight gain and increased appetite
  • history of depression, agitation, or sleep disorders
  • cushingoid exam features
  • history of difficult-to-control diabetes or hypertension
  • absence of hyperpigmentation or autoimmune stigmata
  • medroxyprogesterone use
  • history of treatment for endogenous Cushing syndrome
Full details

Risk factors

  • systemic glucocorticoid administration
  • high potency or dose of exogenous glucocorticoids
  • prolonged glucocorticoid treatment (e.g., >3 weeks)
  • local glucocorticoid administration
  • megestrol use
  • intermittent high-dose exogenous glucocorticoid
  • nonphysiologic scheduling of glucocorticoid dose
  • medroxyprogesterone use
Full details

Diagnostic investigations

1st investigations to order

  • serum comprehensive chemistry panel
  • serum a.m. cortisol
  • adrenocorticotropic hormone (ACTH) stimulation test
  • CBC
  • thyroid function tests
Full details

Investigations to consider

  • insulin tolerance test (ITT)
  • overnight metyrapone test
  • urine synthetic glucocorticoids
Full details

Emerging tests

  • home waking salivary cortisone

Treatment algorithm

INITIAL

features of adrenal crisis

ACUTE

minor intercurrent stress

severe intercurrent stress

ONGOING

stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper

Contributors

Authors

Suzanne L. Quinn Martinez, MD
Suzanne L. Quinn Martinez

Staff Endocrinologist

HCA Florida Orange Park

Program Director, Internal Medicine

Orange Park

FL

Disclosures

SLQM declares that she has no competing interests.

Acknowledgements

Dr Suzanne L. Quinn Martinez would like to gratefully acknowledge Dr M. Cecilia Lansang, a previous contributor to this topic.

Disclosures

MCL is a consultant for the Sanofi group of companies and is an author of several references cited in this topic.

Peer reviewers

Tiffany M Cortes, MD

Assistant Professor of Medicine

Division of Endocrinology

UT Health Science Center San Antonio

San Antonio

TX

Disclosures

TMC declares that she has no competing interests.

Antoine Tabarin, MD

Head

Department of Endocrinology

University Hospital of Bordeaux

Pessac

France

Disclosures

AT declares that he has no competing interests.

Maralyn Druce, MA, MBBS, MRCP, PhD

Clinical Lecturer

Honorary Consultant

Department of Endocrinology

Barts and The London School of Medicine and Dentistry

St Bartholomew's Hospital

London

UK

Disclosures

MD declares that she has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Prete A, Bancos I. Glucocorticoid induced adrenal insufficiency. BMJ. 2021 Jul 12;374:n1380.Full text  Abstract

Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013 Aug 15;9(1):30.Full text  Abstract

Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024 Jun 17;109(7):1657-83.Full text  Abstract

Arlt W; Society for Endocrinology Clinical Committee. Society for Endocrinology endocrine emergency guidance: emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients. Endocr Connect. 2016 Sep;5(5):G1-3.Full text  Abstract

Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020 May;75(5):654-63.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

  • Differentials

    • Primary adrenal insufficiency
    • Pituitary compression, tumor, head trauma, and surgery (non-Cushing)
    • Corticosteroid withdrawal syndrome
    More Differentials

  • Guidelines

    • European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency
    • Adrenal suppression from exogenous glucocorticoids: recognizing risk factors and preventing morbidity
    More Guidelines
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