Adrenal suppression

Last reviewed: 2 Jun 2022
Last updated: 12 Apr 2022

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
More key diagnostic factors

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
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

  • serum comprehensive chemistry panel
  • serum a.m. cortisol
  • salivary a.m. cortisol
  • adrenocorticotropic hormone (ACTH) stimulation test
  • CBC
  • thyroid function tests
More 1st investigations to order

Investigations to consider

  • insulin tolerance test (ITT)
  • overnight metyrapone test
  • urine synthetic glucocorticoids
More investigations to consider

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

Orlando Veterans Administration Hospital

Associate Professor Internal Medicine

University of Central Florida

Orlando

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

Diane Mary Donegan, MB BCh BAO, MRCPI, Ms

Assistant Professor of Medicine

Indiana University

Indianapolis

MI

Disclosures

DMD is a member of a paid advisory board for Recordati and Corcept. DMD is also a site investigator for Corcept and Chiasma.

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.

  • Differentials

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

    • Adrenal suppression from exogenous glucocorticoids: recognizing risk factors and preventing morbidity
    • Emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients
    More Guidelines
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