Symptomatic monitoring for and management of complications during systemic glucocorticoid withdrawal in adults and adolescents who have completed linear growth

AI: adrenal insufficiency; IV: intravenous.

* Depending on the underlying condition, a disease flare may be distinguished from complications of systemic glucocorticoid withdrawal based on a combination of history, physical examination, and laboratory testing. For more information, refer to disease-specific clinical manifestations and diagnosis topics.

¶ Flares of the underlying disease should be treated as outlined in the disease-specific treatment topics, but they often require a temporary increase in the glucocorticoid dose before resuming a more gradual taper.

Δ Moderate to major surgical stress generally refers to surgical procedures that cannot be performed using only local anesthesia. For more information, refer to UpToDate content on the perioperative management of surgical patients taking glucocorticoids.

◊ For more information on management, refer to UpToDate content on the treatment of AI in adults and children.

§ Patients at high risk of AI should receive instruction in the use and indications for higher doses of glucocorticoids (ie, "stress dose") to be given in case of illness, trauma, or moderate to major surgical stress. Patients should also receive education on communicating about AI to medical professionals (eg, use of medical alert tags). For more information, refer to UpToDate information on the treatment of chronic AI.

¥ Our approach is based on monitoring of clinical symptoms. Alternatively, providers may obtain laboratory testing for AI to confirm the diagnosis, with or without obtaining subsequent values to guide the taper. Testing involves omitting the glucocorticoid dose on the morning of the test and measuring an endogenous cortisol level at approximately 7 to 9 AM. For details about this test, refer to UpToDate content on the diagnosis of AI.

‡ Patients with glucocorticoid withdrawal syndrome may have AI; however, AI is unlikely to cause symptoms in patients taking supraphysiologic glucocorticoid doses (eg, >5 mg/day of prednisone, >15 mg/day of hydrocortisone, or >0.25 mg/day of dexamethasone).

† In adults, a supraphysiologic dose is considered to be equal to approximately >5 mg/day of prednisone, >0.25 mg/day of dexamethasone, or >15 mg/day of hydrocortisone. For more information on risk factors for developing glucocorticoid-induced AI and indications for stress-dose glucocorticoids, refer to UpToDate content on discontinuation of systemic glucocorticoids and management of chronic AI.