Adrenal suppression is the inadequate adrenal production of cortisol due to suppression of the hypothalamic-pituitary-adrenal axis.
It may present clinically as adrenal insufficiency in instances of rapid tapering or cessation of exogenous glucocorticoids or withdrawal from endogenous glucocorticoid excess (e.g., following treatment of Cushing's disease or an adrenal tumour causing Cushing's syndrome).
The adrenocorticotropic hormone stimulation test is generally the most useful test to detect adrenal suppression.
Preventive measures include minimising corticosteroid dose and duration when possible.
Treatment consists of augmented corticosteroid therapy plus supportive care for any intercurrent stress or overt signs of adrenal insufficiency.
Adrenal suppression refers to decreased cortisol production as a result of negative feedback on the hypothalamic-pituitary-adrenal axis, caused by excess glucocorticoids. The consequence is decreased production of both corticotropin-releasing hormone from the hypothalamus and adrenocorticotropic hormone from the pituitary gland, leading to a decrease in serum cortisol levels.
History and exam
Key diagnostic factors
- presence of risk factors
- sudden cessation or rapid tapering of glucocorticoids
- acute circulatory collapse with hypotension and tachycardia
Other diagnostic factors
- lassitude and generalised constitutional symptoms
- history of weight gain and increased appetite
- history of depression, agitation, or sleep disorders
- cushingoid examination features
- history of difficult-to-control diabetes or hypertension
- absence of hyperpigmentation or autoimmune stigmata
- medroxyprogesterone use
- history of treatment for endogenous Cushing's syndrome
- systemic glucocorticoid administration
- high potency or dose of exogenous glucocorticoids
- prolonged glucocorticoid treatment (e.g., >3 weeks)
- local glucocorticoid administration
- megestrol use
- non-physiological scheduling of glucocorticoid dose
- medroxyprogesterone use
1st investigations to order
- serum comprehensive chemistry panel
- serum a.m. cortisol
- salivary a.m. cortisol
- adrenocorticotropic hormone (ACTH) stimulation test
- thyroid function tests
Investigations to consider
- insulin tolerance test (ITT)
- overnight metyrapone test
- urine synthetic glucocorticoids
features of adrenal crisis
minor intercurrent stress
severe intercurrent stress
stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
- Primary adrenal insufficiency
- Pituitary compression, tumour, head trauma, and surgery (non-Cushing's)
- Corticosteroid withdrawal syndrome
- Adrenal suppression from exogenous glucocorticoids: recognizing risk factors and preventing morbidity
- Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely
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