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Low-Dose Steroid HPA Risk — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyLow-Dose Steroid HPA RiskSCE Rheumatology

A 60-year-old woman with RA has been on Prednisolone 3 mg daily for 5 years. She wants to stop but is worried about adrenal insufficiency. What dose and duration of Prednisolone carries risk of HPA axis suppression?

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Correct answer: C — Any dose ≥5 mg Prednisolone equivalent for >3 weeks may suppress the HPA axis; even lower doses with prolonged use carry risk requiring gradual tapering not abrupt cessation

HPA axis suppression can occur with Prednisolone doses as low as 5 mg daily for more than 3 weeks. BSR and endocrinology guidance recommend that any patient on glucocorticoids ≥5 mg for >3 weeks should NOT have their steroids stopped abruptly. Gradual tapering is required (typically 1 mg reduction every 2-4 weeks below 10 mg). Assessment of adrenal reserve (9 am cortisol Synacthen test) may be needed before final withdrawal. Patients should carry a steroid emergency card. In this patient on 3 mg for 5 years the HPA axis has likely adapted to the low exogenous dose and slow tapering with monitoring is essential.

Reference: BSR 2025 csDMARD guidelines; Prete A et al 2022 adrenal insufficiency from glucocorticoids