Glucocorticoid-induced Adrenal Insufficiency

Excellent article, thank you.
I appreciated this paragraph on tapering strategies:

“In general, glucocorticoid taper can be faster and in larger decrements if the total daily glucocorticoid dose is high (eg, greater than 30 mg of prednisone). As the total daily glucocorticoid dose is approaching the physiologic daily dose equivalent (greater than equivalent of 15-25 mg hydrocortisone, 4-6 mg prednisone, see Table 1), the taper should be slower and with smaller decrements (Table 4).”

Great discussion and explanation of the HPA axis and its suppression with prednisone. I was surprised to read of actual adrenal cortex atrophy that may occur. The article also speaks optimistically about usual recovery after prednisone is stopped.

I’m in the sub physiologic dose now, and on this information, I’ll continue my very slow taper with more patience!

There are many parts that ring true to me. I found that an endocrinologist's perspective on tapering off Prednisone to be more realistic than my rheumatologist's perspective. I didn't know anything about the risk of HPA axis suppression from long term prednisone use until 10 years after starting prednisone for PMR. Neither my rheumatologist nor my PCP ever mentioned HPA axis suppression or my adrenals.

I know many people are worried about an adrenal crisis but fortunately the article says that is rare. I think an adrenal crisis might only be triggered by something extremely stressful like a car wreck or something worse than that.

"Suppression of the hypothalamic-pituitary-adrenal (HPA) axis is an inevitable effect of chronic exogenous glucocorticoid therapy and recovery of adrenal function varies greatly amongst individuals. Glucocorticoid-induced adrenal insufficiency necessitates careful education and management, and in the rare cases of adrenal crisis, prompt diagnosis and therapy (4)."
https://pubmed.ncbi.nlm.nih.gov/33289121/
I think in most cases the adrenals start to recover if a very low dose of prednisone can be maintained. Full recovery seemed to happen after I discontinued Prednisone. I only had a.m. cortisol levels done after I reached 3 mg of Prednisone.
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My first encounter with an endocrinologist was after my knee replacement surgeries. She introduced herself and her team as part of the "medical management team" and not the surgical team. I didn't know why they came into room to check on me so often. After about 6 hourly visits they left and never returned. As they left, the chief endocrinologist instructed her team that the hydrocortisone infusion could be stopped but to make sure my prednisone dose was reordered.

When I tapered off prednisone, the same endocrinologist was in communication with my rheumatologist. She said I should just stay on 3 mg and not taper any lower. She said 3 mg should be low enough to "encourage" my adrenals to produce more cortisol. After 6 months she said my cortisol level was "adequate."

I was taking Actemra along with 3 mg of Prednisone so I didn't think I needed Prednisone because PMR seemed to be under control. She called my rheumatologist to make sure I didn't need Prednisone for PMR anymore.

The surprise to me was that I could simply stop taking Prednisone. My endocrinologist said 3 mg was a low dose. She said as long as my cortisol level stayed adequate and PMR was under control ... I didn't need to taper from that low of a dose. I was a coward and did a fast taper off Prednisone from 3 mg to zero in a week. My endocrinologist said I should call her if "anything happened."

Something happened but it wasn't a rheumatology or endocrine problem. My ophthalmologist said I needed 60 mg again. That was only a temporary setback. I eventually tapered off Prednisone again 6 months later while a different biologic was tried. In the end I elected to go back on Actemra.

@dadcue I just found this post. I saw the endocrinology guidelines recently and found them helpful, putting it somewhat in perspective. I was diagnosed with GCA with large vessel involvement in March 2026, put on 60 mg prednisone daily and started weekly injections of Actemra in April 2026. I quickly tapered off prednisone to 4 mg by mid-August. I was at 4 mg for 2 weeks and doing fine. When I dropped to 3 mg as prescribed by my rheumatologist, I was extremely tired and had transient headaches, spasm like, that lasted usually only a few minutes. After 2 weeks of fatigue at 3 mg, rheumatology NP put me back to 4 mg for 1 week (I felt much better after a day at 4 mg) and adjusted the taper to 0.5 mg decrease per week. I decreased to 3.5 mg a few days ago and have had extreme fatigue, worse than when I was on 3 mg. After reading your tapering history, it makes me wonder whether I should just deal with the fatigue and continue on the prescribed tapering schedule to get off prednisone as soon as possible. My rheumatologist told me that my #1 goal is to get off prednisone, since my GCA seems to be in remission. He does not believe that I have adrenal insufficiency and my symptoms are due to the prednisone taper. The NP agreed separately. It's hard to know what is tolerable and what isn't as I taper the prednisone. Any thoughts?

Needed for all autoimmune diseases as long term pred has horrible long lasting effect.s

@purplebike

I'm impressed that Actemra was started so soon. To be started on 60 mg of prednisone in March 2026 for newly diagnosed GCA with Actemra started in April 2026 is fantastic in my opinion. To have tapered down by 4 mg by August 2026 is truly amazing! You did in 4 months which used to take years.

Prednisone induced adrenal insufficiency is a side effect from "long term" use. In some cases the adrenals are permanently suppressed. I believe doctors think of adrenal insufficiency in terms of being a permanent condition. Maybe your doctor doesn't believe you have "permanent" adrenal insufficiency but your adrenals might be temporarily suppressed. In that case, your symptoms are probably caused by the fast prednisone taper which should improve as your dose is decreased more slowly.

I don't think anyone knows if your prednisone taper is "too fast" or "too slow" since you are also taking Actemra. I think it is important to taper off Prednisone as soon as possible. That is where it gets tricky because nobody knows how much prednisone is too much or not enough. It is also difficult to know when it becomes "too long" to be on prednisone.

As far as what symptoms are tolerable is based solely on what is tolerable for you. However, I think you have to be able to tolerate "some fatigue" and "some discomfort" to get to zero prednisone.

@dadcue Thanks for your advice. It all makes sense. I'm retired, and for the most part, if I'm tired, I can take a nap. I do have a spouse with some disabilities, so that makes it a little trickier. I will persevere and hope that my adrenals kick in sooner than later and that prednisone doesn't ruin my bones and cardiovascular system before then.

Actemra is the reason I was able to taper prednisone quickly. Despite the seemingly quick Actemra prescription, my diagnosis of GCA was not simple. There was a mis-start along the way. I started 60 mg prednisone at the end of January 2026 when I first had excruciating headaches and elevated CRP & ESR. I had only been on prednisone for 3 days when I had a temporal artery biopsy which was negative. The length of the segment taken was about half the optimal size. I didn't know to ask for a 3cm segment at surgery. I was able to convince my PCP to refer me to the fast-track GCA clinic at Mass General Brigham in Boston so I could have a vascular ultrasound (VUS). I was seen within a week of referral by a rheumatologist and had a VUS of my one remaining temporal artery, carotids, and subclavians. All negative, but I had been on prednisone for 3 weeks. At this point, my rheumatologist thought I might have crown dens syndrome (essentially pseudogout of the proximal cervical spine), which is very rare, but I have had pseudogout in my hands a few times. Crown dens goes away on its own typically with a short course of anti-inflammatories. So I did a very, very fast taper on the prednisone, 60 to 0 in a month. My symptoms returned. I also started having lower limb claudication. All this indicated that I didn't have crown dens. At that point a PET/CT was ordered which took another 3 weeks to get scheduled. During that wait time, I stayed off prednisone so it would not interfere with the result of the PET/CT. It was a horrible experience. I barely managed by taking large doses of CBD oil and Tylenol. My PET/CT confirmed the diagnosis of GCA. I restarted prednisone at 60mg right away and got Actemra approved and delivered in a few weeks.

I don't fault the rheumatologist for thinking that I might have crown dens. I'm Asian, and GCA in Asians is EXTREMELY rare. I'm one of the outliers. I do credit my PCP for thinking right off the bat that I might have GCA and making the referral to Boston. My PCP also ordered a PET/CT early on but insurance denied it. I would have been diagnosed weeks earlier had insurance let me have the test.

@purplebike You might try tapering to 3.5 on day one, then 4.0 on day two, then 3.5 on day three, then 4.0 on day four. Keep this up for 10 to 14 days. If you are pain free then you can try moving to 3.5 or alternately you can do 3.5 for two days, the 4.0 for one day, then 3.5 for two days, then 4.0 for one day. Keeping this up for 10-14 days before going to 3.5mg prednisone.
Getting below 4.0mg is very much an individual journey and what works fr you is the right path for you.
I am now using the rule that I must be pain free and my inflammatory markers must be in the green zone before I will taper down any. If either of these is not true I will stay at my current dose for another month and test my inflammatory markers again. I have had PMR Dx since March 2020 and GCA since Oct 2025.

@purplebike

Incredible story leading up to being diagnosed with GCA. How did you know that you could try a "burst of prednisone" by going from 60 mg to zero in one month? I have another autoimmune condition which was treated that way. I did the same and tapered from 60 mg to zero in a month. It wasn't always a straight line taper to zero because some days I had to increase my dose for a day or two before tapering lower. My symptoms from the other autoimmune condition were less complicated than PMR because I knew exactly how much inflammation was present each day so I could adjust my Prednisone dose accordingly.

PMR was more complicated because my inflammation couldn't be measured each day. Being on Actemra made my inflammation markers less reliable. I would like to add that an endocrinologist checked my morning cortisol level before I discontinued Prednisone. I was on 3 mg of Prednisone and did a "countdown taper" by going from 3-2-1-zero by decreasing by 1 mg daily before going back to 3 mg again. I did this several times to see what happened first before I actually stopped taking prednisone permanently. By this time, I was relatively certain Actemra was working for PMR and the endocrinologist reassured me that my cortisol level was adequate.

@jabrown0407 Thanks for the suggestions. I suggested something similar to the rheumatology NP. He wasn't interested in my trying that and thought I should try a straight line decrease of 0.5 mg per week after bumping back up to 4 mg. I fortunately don't have any pain associated with GCA as the Actemra is taking care of that (I hope). My main complaint is fatigue with occasional dizziness and minor/transient headaches. In addition, Actemra interferes with the normal ESR and CRP pathways. Those measures are no longer indicative of the disease. I'm pretty sure that my symptoms now are a result of prednisone withdrawal and not disease flare. My rheumatologist and the NP agree. If I can't get past 3.0 mg again, I may try a seesaw approach on my own or a slower taper of 0.25 mg. I have been prescribed the liquid prednisone and can measure out what I want/need. I haven't tried it yet, but know that it tastes awful. I read that it can be mixed with chocolate syrup or peanut butter to help with the extreme bitter taste.