Practice Guideline

. 2024 Jun 17;109(7):1657-1683.

doi: 10.1210/clinem/dgae250.

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Felix Beuschlein^{1

2

3}, Tobias Else⁴, Irina Bancos^{5

6}, Stefanie Hahner⁷, Oksana Hamidi⁸, Leonie van Hulsteijn^{9

10}, Eystein S Husebye^{11

12}, Niki Karavitaki^{13

14

15}, Alessandro Prete^{13

14

16}, Anand Vaidya¹⁷, Christine Yedinak¹⁸, Olaf M Dekkers^{10

19

20}

Affiliations

¹ Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), 8091 Zürich, Switzerland.
² Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, 81377 Munich, Germany.
³ The LOOP Zurich Medical Research Center, 8044 Zurich, Switzerland.
⁴ Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA.
⁵ Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA.
⁶ Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
⁷ Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany.
⁸ Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX 75390-8857, USA.
⁹ European Society of Endocrinology, Bristol BS32 4QW, UK.
¹⁰ Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
¹¹ Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway.
¹² Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway.
¹³ Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
¹⁴ Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK.
¹⁵ Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
¹⁶ NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
¹⁷ Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
¹⁸ Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR 97239-3098, USA.
¹⁹ Department of Endocrinology and Metabolism, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
²⁰ Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus, Denmark.

PMID: 38724043
PMCID: PMC11180513
DOI: 10.1210/clinem/dgae250

Practice Guideline

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Felix Beuschlein et al. J Clin Endocrinol Metab. 2024.

. 2024 Jun 17;109(7):1657-1683.

doi: 10.1210/clinem/dgae250.

Authors

Affiliations

¹ Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), 8091 Zürich, Switzerland.
² Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, 81377 Munich, Germany.
³ The LOOP Zurich Medical Research Center, 8044 Zurich, Switzerland.
⁴ Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA.
⁵ Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA.
⁶ Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
⁷ Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany.
⁸ Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX 75390-8857, USA.
⁹ European Society of Endocrinology, Bristol BS32 4QW, UK.
¹⁰ Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
¹¹ Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway.
¹² Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway.
¹³ Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
¹⁴ Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK.
¹⁵ Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
¹⁶ NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
¹⁷ Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
¹⁸ Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR 97239-3098, USA.
¹⁹ Department of Endocrinology and Metabolism, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
²⁰ Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus, Denmark.

PMID: 38724043
PMCID: PMC11180513
DOI: 10.1210/clinem/dgae250

Abstract

Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.

Keywords: adrenal crisis; adrenal insufficiency; glucocorticoid withdrawal; glucocorticoids; steroids; substitution therapy.

This article has been co-published with permission in The Journal of Clinical Endocrinology & Metabolism and European Journal of Endocrinology. © The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society.

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Figures

**Figure 1.**
Schematic representation of HPA axis recovery following discontinuation of supraphysiologic glucocorticoid therapy (adapted from: Prete and Bancos 2021 (58)).

**Figure 2.**
Proposed approach to systemic glucocorticoid discontinuation.

**Figure 3.**
Management of patients at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency with suspected adrenal crisis or during exposure to stress.

See this image and copyright information in PMC

References

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European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Affiliations

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Authors

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

Substances

Grants and funding

LinkOut - more resources

Full Text Sources

Medical