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Glucocorticoid-induced adrenal insufficiency during prednisolone withdrawal — SCE Rheumatology MCQ

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ModerateGlucocorticoidsGlucocorticoid-induced adrenal insufficiency during prednisolone withdrawalSCE Rheumatology

A 71-year-old woman with polymyalgia rheumatica has received prednisolone for 20 months. Her disease has been clinically quiescent for 9 months, and the dose has been reduced using a slow taper. On each of two attempts to reduce prednisolone from 3 mg to 2 mg daily, she has developed anorexia, nausea, profound fatigue and postural light-headedness. She has no recurrent shoulder or hip-girdle pain, morning stiffness, synovitis, headache or visual symptoms. ESR and CRP remain normal, and the symptoms resolve when prednisolone 3 mg daily is reinstated. An 08:30 serum cortisol is measured after prednisolone has been paused for 24 hours. The result is 138 nmol/L using a modern immunoassay. She resumes prednisolone 3 mg after the blood test and remains haemodynamically stable. Which management plan is most appropriate?

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Reveal the answer and explanation

Correct answer: C — Continue physiological-equivalent glucocorticoid replacement and refer her to endocrinology

Explanation lettering: C = shown as B · B = shown as C

The recurrent systemic symptoms below the physiological-equivalent prednisolone dose, in the absence of polymyalgic symptoms or an inflammatory-marker rise, indicate glucocorticoid-induced adrenal insufficiency rather than relapse. The cortisol was appropriately measured between 08:00 and 09:00 after prednisolone had been paused for 24 hours. A result below 150 nmol/L requires glucocorticoids to be restarted or continued at a replacement dose and referral to endocrinology. Stopping prednisolone (A) is appropriate when cortisol is above 300 nmol/L, when adrenal insufficiency is very unlikely; withdrawal symptoms alone cannot safely explain this result. Repeating the cortisol without referral (C) is the strategy for the indeterminate 150–300 nmol/L range, with referral if it remains indeterminate. A short Synacthen test may subsequently be arranged by endocrinology, but replacement should not be withheld while awaiting dynamic testing (D). Increasing prednisolone to an anti-inflammatory dose (E) would be appropriate for a genuine polymyalgia rheumatica relapse, characterised by recurrent girdle pain and stiffness, usually with supportive inflammatory activity. Those features are absent here. Adults should not routinely be switched from prednisolone to hydrocortisone solely to facilitate withdrawal.

Reference: Adrenal insufficiency: identification and management (NG243) — Managing glucocorticoid withdrawal to prevent adrenal insufficiency (Published 28 August 2024; minor updates through October 2025) — https://www.nice.org.uk/guidance/ng243/chapter/recommendations