Intended for healthcare professionals

Practice Easily Missed?

Glucocorticoid induced adrenal insufficiency

BMJ 2022; 379 doi: (Published 10 November 2022) Cite this as: BMJ 2022;379:e065137
  1. Aoife Garrahy, post-CCT fellow in endocrinology1,
  2. Jeremy W Tomlinson, professor of metabolic endocrinology1 2,
  3. Aparna Pal, consultant endocrinologist1
  1. 1Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
  2. 2NIHR Oxford Biomedical Research Centre, Oxford, UK
  1. Correspondence to: A Garrahy draoifegarrahy{at}

What you need to know

  • Educate patients taking prednisolone ≥5 mg/day or equivalent for more than four weeks, 40 mg prednisolone or equivalent for longer than one week, or repeated short courses of glucocorticoids via any route (≥3 per year), about the risk of glucocorticoid induced adrenal insufficiency (GC-AI)

  • Advise patients at risk of GC-AI to increase their dose of glucocorticoid when unwell and issue them with a steroid emergency card

A 72 year old woman presents to her general practitioner with a two week history of fatigue, nausea, and poor balance. She has recently completed a three month course of prednisolone for polymyalgia rheumatica. Investigations show she is euvolaemic with a serum sodium of 126 mmol/L (reference range 133-145 mmol/L), urine sodium 35 mmol/L, and urine osmolality 560 mOsm/kg. A serum cortisol is not measured. Based on her history and these results, she receives a diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and is advised to restrict her fluid intake. She reduces fluids, but experiences similar symptoms and worsening hyponatraemia in the subsequent four weeks, and is referred to hospital. On admission to hospital, her serum cortisol is 124 nmol/L (4.5 μg/dL), synacthen test shows suboptimal cortisol response (30 minute cortisol 216 nmol/L (7.8 μg/dL)), and adrenocorticotropic hormone (ACTH) is normal (7.4 ng/L). A diagnosis of glucocorticoid induced adrenal insufficiency (GC-AI) is made following a normal pituitary magnetic resonance imaging (MRI) scan. With glucocorticoid treatment, her serum sodium normalises.

What is glucocorticoid induced adrenal insufficiency?

Adrenal insufficiency is characterised by inadequate glucocorticoid production by the adrenal gland.1 GC-AI occurs as a result of suppression of the hypothalamic-pituitary-adrenal axis secondary to prolonged exposure to glucocorticoids,2 and is among the most common types of adrenal insufficiency encountered in clinical practice.2 In contrast to primary adrenal insufficiency, which is a disease of the adrenal cortex (eg, …

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