Glucocorticoid-induced Adrenal Insufficiency

@dadcue, thank you for posting this.

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.