A 48-year-old lady has been referred from her primary physician to rule out Cushing’s disease. She has been suffering with bronchial asthma for 20 years, with acute exacerbations at least 3 times/year requiring hospital admissions. She is on inhaled steroids everyday with use of oral steroids for 1–2 weeks at least 4–6 times/year. She is also diagnosed to have diabetes and hypertension for 5 years and is on treatment. She had sustained fracture of the left wrist following a trivial fall a year ago. On examination, she has central obesity, abdominal striae, thin skin and hypertension. Her primary physician ordered for an 8 am cortisol which showed 28 mg/dL. After receiving the patient, it is revealed that the patient was continuing to use prednisolone 10 mg/day without disclosing to her doctor. She is educated about being off all medications and a repeat 8 am cortisol is ordered which is 2 mg/dL this time suggesting exogenous cortisol use.
What are the factors to be considered while withdrawing steroids?
The discontinuation of steroid therapy can present a significant clinical challenge and following three factors need to be considered while withdrawing steroids—(1) the possibility of suppression of the hypothalamic–pituitary–adrenal (HPA) axis and resulting secondary adrenal insufficiency, (2) the possibility of worsening of the underlying disease for which steroid therapy was initiated, and (3) a phenomenon, sometimes called the steroid withdrawal syndrome, in which some patients encounter difficulty, and even significant symptoms, discontinuing or decreasing steroid doses despite having demonstrably normal HPA axes.
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