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Glucocorticoid-induced adrenal insufficiency during oral corticosteroid withdrawal in severe asthma — SCE Resp

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HardSystemic CorticosteroidsGlucocorticoid-induced adrenal insufficiency during oral corticosteroid withdrawal in severe asthmaSCE Respiratory

A 48-year-old woman with severe eosinophilic asthma has taken maintenance prednisolone 10 mg daily for 30 months. Nine months after starting benralizumab, she has had no exacerbations, her symptoms and peak-flow variability have substantially improved, and FEV1 has remained stable during a supervised slow prednisolone taper. Ten days after reducing prednisolone from 3 mg to 2 mg daily, she develops profound fatigue, anorexia, nausea and postural light-headedness. There is no wheeze, cough, fever or increase in reliever use. Supine blood pressure is 118/72 mmHg and standing blood pressure is 94/60 mmHg. Serum sodium is 132 mmol/L, potassium 4.2 mmol/L and glucose 4.8 mmol/L. An 08:20 serum cortisol, measured using a modern immunoassay after prednisolone has been withheld for 24 hours, is 86 nmol/L. She is not vomiting and remains haemodynamically stable after oral fluids. Which management plan is most appropriate?

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Correct answer: D — Increase prednisolone to 8 mg daily until symptoms resolve, reduce to 4 mg daily for 1 week, then resume a slower taper and refer to endocrinology

Her respiratory disease remains objectively controlled, whereas symptoms appeared only after prednisolone fell below the adult physiological-equivalent range of 3–5 mg daily. Postural symptoms, anorexia, nausea and hyponatraemia therefore indicate glucocorticoid-induced adrenal insufficiency rather than recurrent asthma. The cortisol was sampled appropriately after withholding prednisolone for 24 hours and is below 150 nmol/L. NICE recommends double the physiological-equivalent glucocorticoid dose until symptoms resolve, followed by a physiological dose for 1 week and then a slower taper. Prednisolone 8 mg followed by 4 mg implements that sequence. A cortisol below 150 nmol/L during withdrawal also requires glucocorticoid restoration and endocrinology referral. A is unsafe because symptomatic adrenal insufficiency should be treated rather than observed; repeat testing is principally relevant to an indeterminate result of 150–300 nmol/L. C delays necessary glucocorticoid treatment while pursuing a dynamic test that is not required before acting on this result. D mistakes steroid-withdrawal adrenal insufficiency for asthma relapse despite stable lung function, peak flow and respiratory symptoms. E includes unnecessary mineralocorticoid replacement: glucocorticoid-induced tertiary adrenal insufficiency is treated with glucocorticoid replacement alone. NICE also advises against routinely changing adults from prednisolone to hydrocortisone merely to manage withdrawal below physiological doses.

Reference: Adrenal insufficiency: identification and management (NG243) — Recommendations (Published 28 August 2024; minor changes through October 2025) — https://www.nice.org.uk/guidance/NG243/chapter/recommendations Adrenal insufficiency: identification and management (NG243) — Update information (October 2025) — https://www.nice.org.uk/guidance/NG243/chapter/update-information