Hi all - I just wrote an absolute essay in response to a question about adrenal insufficiency (AI from now on in this post) from steroids. Since this is a question that may crop up periodically (I know I've answered it before), I thought I would copy it here for general information, and to link to in other posts if anyone wants to know about tests, what AI is, how it's treated etc. This may start to be more common if asthmatics who were previously steroid dependent are able to taper down their steroids after responding well to biologics. Or for weirdos like me who don't respond to pred but took too long to realise... Obviously be aware I'm not a doctor and this isn't medical advice - it's my experience plus some basic knowledge you can find online.
This website, plus two others I have linked to below, may be helpful. Please note that it talks about Addison's Disease which as I explain below is actually just one type of AI, but it does include information about secondary AI and about adrenal crisis: addisonsdisease.org.uk/addi...
This is really long, apologies in advance, but I hope it’s useful! I have added extra information about basic cortisol blood tests as well as the short synacthen tests that Mark-F asked about (please note you can also have a full day test to measure cortisol levels more closely but it seems uncommon for secondary AI from steroids and I have no personal experience, so haven't included that here).
I have adrenal insufficiency from long term pred (in my case 15 months and 1 year long courses with lots of short courses in between). I have very weird asthma and I don't really respond to oral steroids, so my specialist clinic managed to get me off pred which I'm very grateful for - sadly the weirdness also means I'm not eligible for any mAbs! However, coming off pred also revealed that my adrenals weren't happy so now I have AI.
Usually with AI that results from steroid use it's technically not Addison's disease, though you may hear that used as a general term for AI. Addison's is usually used to refer to a type of primary AI; with Addison's your adrenals don't work to produce cortisol and some other hormones that regulate salts. With AI from steroids it's generally a type of secondary AI, and usually the issue is just with cortisol production and not other hormones. The pituitary gland usually tells your adrenals to produce cortisol with a hormone called ACTH, but with secondary AI from steroids, the pred basically told your pituitary gland that you already had cortisol, so it didn't bother to keep stimulating the adrenals with ACTH to produce any more. When you stop the pred, your pituitary might not pick up the idea that it needs to produce ACTH again, and therefore the adrenals won't bother to produce cortisol. Sometimes the pituitary can start working again and sending ACTH (so you can sometimes recover from secondary AI if it's steroid-induced, which you cannot from Addison's), but sometimes the adrenals just stop bothering and won't produce what they need even when stimulated with ACTH.
This link may help: hopkinsmedicine.org/health/...
EDIT: It is possible to get AI from inhaled steroids only, but it is fairly uncommon and would usually happen with higher doses. This isn't a reason not to take your inhaled steroids: AI can be managed, dying from asthma because you were worried about the risk of AI cannot (to put it bluntly) - so don't run the high risk of a serious asthma attack to avoid the much lower risk of AI. (This actually applies to all kinds of steroids: if you need them for asthma, you need them).
It's also possible to get AI from multiple repeated short courses of oral steroids. Everyone is different, and some people can tolerate high doses without much effect, others will have a lot of side effects and get AI on lower steroid doses.
You might get an initial cortisol test with your GP/clinic: this will not be massively helpful if you are still on higher levels of steroids and/or it's done randomly. You need to have got down to about 5mg and be able to stop steroids for a short time, usually 24 hours, for this to be useful, and it needs to be done at 8-9am so they can compare reference ranges: time of day is very important for cortisol! If this is very low it shows you have a problem. If it's normal, and was done properly (ie right time, off steroids for long enough) then you probably don't have AI. If it's in between, they should do a short synacthen test to get more information about your adrenals and pituitary.
The short synacthen test is basically looking to see what happens to your cortisol levels when they’re stimulated with ACTH, so they ask you to stop steroids for at least 24 hours beforehand (that includes any nasal sprays and also your steroid inhaler as well as pred.) I would definitely talk to your asthma team if there are any problems with stopping. My original instructions said try to stop steroid inhaler for 48 hours; I did 36 and had an admission shortly after which my endocrine nurse specialist felt might be related to missing 3 doses of Fostair, so she said not to stop for more than 24 hours - this is fine for the test. EDIT: I've now been asked to stop my Avamys nasal spray for *72* hours before the test; the others are the same so far.
The test should be scheduled to start at 9am and you might feel a bit grim from stopping the steroids, so if you're travelling to have it it may be worth staying nearby the night before – though not the end of the world if you can’t. Also a good idea to take something to do as you just sit there in the test for an hour plus.
A nurse will check your vital signs, put in a cannula, ask what steroid-containing meds you take and when you last had them. A doctor should then come and talk to you to explain the test and get your consent. The nurse will then take your blood at 9am (or as close to it as possible – cortisol levels vary throughout the day and are highest in the morning, and they use 8am or 9am reference ranges). Then you’ll get an injection of synacthen (artificial ACTH) and they will take blood half an hour later, then half an hour after that. Once that’s done the test is over and you can take all your drugs again – yay! So make sure to bring them to the test. I am the person who makes noises and ends up needing Ventolin every time I have this test (3 times now), because apparently lungs need those inhaled steroids even if I don’t do much with pred.
They’re looking to see what your baseline cortisol and ACTH levels are and what they are at 30 mins and 60 mins. If you can get above a certain level of cortisol then most likely everything is fine. If you don’t, it means your adrenals aren’t producing the cortisol they should and you need to replace it. In my case my baseline cortisol in all three tests has been above the ‘concerning’ level but below the ‘ok’ level, but then doesn’t rise to the level it should at 30 and 60 minutes despite the ACTH (and my own ACTH levels are fine too), so I have secondary AI - which I may still recover from and they are retesting to see.
If you do turn out to have AI, you should be referred to an endocrine specialist – I see a fantastic nurse specialist who I wish I could clone as an asthma nurse lol. Most drs/nurses who are not in endocrinology appear to be deeply scared of the entire area and will do all sorts of odd things, so it’s worth educating yourself as you will probably need to guide non-endos if you are admitted to hospital. (My endo nurse clearly knows this and has provided me with various numbers for the endo dept ‘in case you have any trouble). Your asthma team should know the basics but they should not be trying to manage AI without endocrinology input, so push them if they don’t refer you.
For treatment: you can take pred but it’s more usual to take 20mg of hydrocortisone in divided doses (20mg hydrocortisone =5mg pred; hydro is less strong than pred and lasts less time, but is closer to your natural cortisol). That dose may vary but 20mg is the usual starting dose. The highest dose is in the morning as that’s when your natural cortisol production is highest and you need to try to replicate that - dose timing is important. I was prescribed it twice a day but do 10mg about 6am (I wake up earlier than I need to, take it then go to sleep again), 5mg at about 11.30am with my Phyllocontin and 5mg at 4pm. This was after I joined a Facebook group (Adrenal Diseases Self Help Group – lots of useful info if you’re on FB). I did start with one dose of 5mg pred in the morning but I was feeling absolutely dead by the evening on that, so the switch to hydro split doses really helped. Also as it’s a low dose and replacing your natural cortisol, you are unlikely to get the side effects as with high pred doses.
They tried seeing if I could reduce my dose to get my adrenals working again but it didn’t last so I’m back up to 20mg total in the three doses.EDIT: made it down to 10mg baseline total daily dose again in 2021
You will also need to updose (usually double each dose, so for me it was 20mg 6am, 10 mg 11.30am, 10mg 4pm) if you are ill or seriously injured, because illness is physiologically stressful for the body, and that uses cortisol you're not producing. There is guidance on this but you may find you need to tweak it eg it says you don’t need to for colds, but I find I often need to because colds trigger my asthma.) In general my asthma absolutely gobbles cortisol so I will updose if it’s flaring even if not hospital level. You’ll also need it for some procedures (including major dentistry, surgery, and things like colonoscopy – never had any of those so far thankfully but I know I’d need to updose). Fevers also tend to mess with cortisol. You do not usually need to updose for 'normal' emotional stress like exams (unless that really sets off asthma), but may need to for something like a bereavement or a major shock.
The one time I have had an adrenal crisis so far was a virus setting off asthma – I tripled what was my baseline dose then and it wasn’t enough. (Should it be relevant, official advice for COVID if you have AI is to quadruple the baseline dose). My endocrine nurse has commented that there is a bit of a lack of information for people who have steroid-induced AI in terms of how it works for illness, taking steroids for the asthma etc so be aware of that.
You should definitely ask whoever you see for advice on updosing and how to recognise low cortisol and crisis in yourself, though that may also be individual. For me low cortisol - which isn't the same as crisis but might become one if I don't get on top of it - is feeling very very sluggish, hard to wake up, very slow brain, bit dizzy. When I had a crisis I also threw up twice and thought I had norovirus, but since the injection sorted me out it clearly was the crisis itself (though vomiting from other causes has specific guidance - ask about this as you may need to take special steps if you have eg a stomach bug with AI, such as visiting urgent care when others wouldn't need to).
You will also need to ask for an emergency hydrocortisone injection and be shown how to use it (I was convinced I would not be able to, but I did it despite the fact that adrenal crisis can make you into an absolute idiot in my limited experience. I took far too long to work out I should use it - but I did it and I have no experience of injecting myself.) Always take the kit with you on trips, and ideally have two so you can keep one with you at work, one at home etc.
EDIT: Hilary39 has also reminded me that keeping a strip of hydrocortisone tablets on you at all times is also a good idea. Even in hospital steroid treatment can be delayed/withheld, or you might be out and have forgotten you need a dose.
Please also see below for Hilary's reply if you are pregnant and have AI.
Finally, you will need to get some kind of medical alert bracelet/tag that says you are steroid dependent and have AI - that doesn't have to be an expensive official one, I have a bangle from Amazon which does the job where I told them what to engrave. The Pituitary Foundation also has useful resources and advice: pituitary.org.uk/informatio...
I’ll stop now as this is already a huge essay - if you got all the way to the end well done and I hope it was helpful! 😊 Please feel free to add any comments from your own experience of AI, or ask questions if I wasn't clear.