Synopsis
Identify hypothalamic-pituitary-adrenal suppression from every glucocorticoid route, separate withdrawal from disease relapse, and taper safely while maintaining stress cover and crisis readiness.
- Exogenous glucocorticoids suppress CRH and ACTH, causing adrenal atrophy; recovery varies widely and cannot be predicted from dose duration alone.
- Count oral, injected, inhaled, intranasal, topical and rectal exposure together, including repeated joint injections and CYP3A4 interactions that increase systemic steroid concentrations.
- For adults treated longer than four weeks, reduce toward a physiological equivalent only after the underlying inflammatory or malignant indication no longer requires a higher therapeutic dose.
Key red flags
Hypotension, collapse, confusion, hypoglycaemia or severe vomiting after steroid reduction warrants immediate treatment for adrenal crisis without awaiting cortisol results.
Investigation priorities
Estimate suppression risk across prescription, procedure and non-prescription routes.
Management branches
A systemic or locally delivered glucocorticoid course is being reduced or stopped.
- List all preparations, duration, cumulative pattern, depot injections and interacting medicines, and identify the prescriber responsible for the original disease.
- Decide whether therapeutic steroid is still required; do not taper inflammatory control merely to perform an endocrine test.
Key medicines
Physiological glucocorticoid coverUse the NICE equivalent replacement range, commonly hydrocortisone 15 to 25 mg daily in divided doses, while assessing axis recovery.
Oral sick-day hydrocortisone or prednisoloneDuring significant adult physiological stress, NICE advises at least 40 mg hydrocortisone daily or 10 mg prednisolone daily until recovery.