New joint guideline focuses on treatment of glucocorticoid-induced adrenal insufficiency
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Key takeaways:
- Providers should educate patients when prescribing glucocorticoid therapy.
- Tapering off glucocorticoids should be individualized for each patient.
- Providers should monitor for symptoms of adrenal insufficiency.
Glucocorticoid tapering, education and treatment of adrenal crisis are three of the main focuses of a new clinical practice guideline on glucocorticoid-induced adrenal insufficiency.
The Endocrine Society and the European Society of Endocrinology published a joint clinical practice guideline on the management of glucocorticoid-induced adrenal insufficiency in May. The guideline is critical, according to Felix Beuschlein, MD, professor and director of the department of endocrinology, diabetology and clinical nutrition at the University of Zürich in Switzerland and co-chair of the guideline working group, as 1% of the global population uses glucocorticoids and could be at risk for glucocorticoid-induced adrenal insufficiency. Beuschlein said the guideline, which was published in both The Journal of Clinical Endocrinology & Metabolism and European Journal of Endocrinology, is the first comprehensive statement published by major endocrinology societies on the condition.
“Glucocorticoid-induced adrenal insufficiency can result in serious health consequences, including adrenal crises, which can be life-threatening if not properly managed,” Beuschlein told Healio. “The guideline aims to standardize the evaluation and management of glucocorticoid-induced adrenal insufficiency, improving patient outcomes and safety, yet minimizing the risk of prolonged glucocorticoid treatment.”
Guidance for tapering off glucocorticoids
A large part of the guideline informs providers of how to taper off of glucocorticoid therapy for people with nonendocrine conditions. The statement recommends tapering glucocorticoid therapy down to the physiologic daily dose equivalent for people on long-term therapy once the underlying disease is controlled. Glucocorticoids should not be tapered for those on short-term therapy of less than 3 to 4 weeks.
“The tapering process should be individualized, considering factors such as the patient’s comorbidities, duration of glucocorticoid therapy, and risk of adrenal insufficiency,” Beuschlein said. “Clinicians should monitor for signs of adrenal insufficiency and be prepared to adjust the tapering schedule or provide stress doses of glucocorticoids during periods of illness or stress.”
For people who are receiving a physiologic daily dose equivalent and wanting to discontinue glucocorticoid therapy entirely, providers can continue to taper down the glucocorticoid dose while monitoring for symptoms of adrenal insufficiency or test morning serum cortisol levels. Morning serum cortisol is recommended as a first test to confirm recovery of the hypothalamic-pituitary-adrenal axis.
Patients who want to discontinue glucocorticoids without recovery of the hypothalamic-pituitary-adrenal axis in 1 year on the physiological daily dose or those with a history of adrenal crisis should be assessed by an endocrinologist, according to the guideline.
Managing glucocorticoid-induced adrenal insufficiency
There are several symptoms of glucocorticoid-induced adrenal insufficiency providers should be aware of, including fatigue, nausea, hypotension, hypoglycemia and weight loss. Beuschlein said providers also need to look for signs of adrenal crisis, such as severe hypotension, dehydration and electrolyte imbalances, which require immediate medical attention.
For people with adrenal stress who did not undergo biochemical testing to rule out glucocorticoid-induced adrenal insufficiency, stress dose coverage should be prescribed. Oral glucocorticoids can be used for minor adrenal stress and for people with no signs of hemodynamic instability or prolonged vomiting or diarrhea. For those with moderate or severe stress, parenteral glucocorticoids should be prescribed.
The recommendations state a diagnosis of adrenal crisis should be considered for anyone who is using or recently used glucocorticoids and presets with hemodynamic instability, vomiting or diarrhea, regardless of the type of glucocorticoid used. These patients should receive parenteral glucocorticoid therapy and fluid resuscitation.
The consensus guideline also discusses how providers who prescribe glucocorticoids should educate their patients about how the medications can affect the endocrine system and provide them with up-to-date information. The recommendation add that people tapering off glucocorticoids for nonendocrine conditions do not need to be seen by an endocrinologist.
More research needed
More data are required to further refine recommendations in the future, according to Beuschlein. Many of the recommendations in the consensus statement were based on very low-quality evidence or on the good clinical practice and experience of the guideline working group.
“Key outstanding questions include the optimal tapering schedule to minimize the risk of glucocorticoid-induced adrenal insufficiency, the most reliable diagnostic tests for assessing adrenal function recovery and the long-term outcomes of patients with glucocorticoid-induced adrenal insufficiency,” Beuschlein said. “Further research is needed to establish evidence-based protocols for glucocorticoid tapering and to develop new biomarkers for early detection and monitoring of adrenal insufficiency.”
According to a press release, the consensus statement is the first of several that the Endocrine Society and European Society of Endocrinology plan to release in the coming years. The organizations plan to publish joint guidelines on diabetes in pregnancy in 2025, arginine vasopressin resistance and arginine vasopressin deficiency in 2026 and male hypogonadism in 2027.
References:
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Beuschlein F, et al. J Clin Endocrinol Metab. 2024;doi:10.1210/clinem/dgae250.
- Endocrine Society and European Society of Endocrinology publish joint guideline on glucocorticoid-induced adrenal insufficiency. https://www.endocrine.org/news-and-advocacy/news-room/2024/endocrine-society-and-european-society-of-endocrinology-publish-joint-guideline. Published May 13, 2024. Accessed May 15, 2024.
For more information:
Felix Beuschlein, MD, can be reached at felix.beuschlein@usz.ch.
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