Adrenal Insufficiency
Question# 854
I have a question about prednisone, or more so the physiological withdrawal presentation if a patient ceases abruptly his treatment plan.
I had a patient who called due C/O a few days of generalized weakness, joint pain, abdo pain, nausea/diarrhea. Two weeks prior, he had a skin graph for a Chronic non-healing wound. Pt was also C/O pain to the extremity where he had the autograft. No purulent discharge, no edema, hyperthermia, no Erythema noted at the surgery site.
H: COPD, Rheumatoid Vasculitis, IDDM, osteoporosis, Recent Sx skin graph.
M: Prednisone 30Mg , apixaban, metformin, lantus, Salbutamol, -see list
Pt was febrile W/ temp 38.4C , HR 130, BP 149/90 RR 28, SPO2 98 % RA, B.S 8.1 MMOL, Skin was hot, moist and flushed, with a blotch red skin on his chest, Pt denies having a rash . Pt states had ran out of his prednisone X 3 days . We transported, query sepsis and maybe certain symptoms caused by prednisone withdrawal. Could this Pt have adrenal insufficiency o crisis?
I had a patient who called due C/O a few days of generalized weakness, joint pain, abdo pain, nausea/diarrhea. Two weeks prior, he had a skin graph for a Chronic non-healing wound. Pt was also C/O pain to the extremity where he had the autograft. No purulent discharge, no edema, hyperthermia, no Erythema noted at the surgery site.
H: COPD, Rheumatoid Vasculitis, IDDM, osteoporosis, Recent Sx skin graph.
M: Prednisone 30Mg , apixaban, metformin, lantus, Salbutamol, -see list
Pt was febrile W/ temp 38.4C , HR 130, BP 149/90 RR 28, SPO2 98 % RA, B.S 8.1 MMOL, Skin was hot, moist and flushed, with a blotch red skin on his chest, Pt denies having a rash . Pt states had ran out of his prednisone X 3 days . We transported, query sepsis and maybe certain symptoms caused by prednisone withdrawal. Could this Pt have adrenal insufficiency o crisis?
Answer:
Adrenal insufficiency precipitated from withdrawal of a patient’s corticosteroid medication will often begin manifesting within the first 24hr of the patient no longer taking their prescription. Different patients may present differently; however, it was documented that the predominant manifestation of adrenal crisis is hypotension with cardiovascular collapse (shock), but patients will also have nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma. Additional to this, fever is usually caused by infection but may be exaggerated by hypocortisolemia, and it should be assumed it indicates infection that should be identified and treated.
Referring to the patient you recently encountered, it is feasible that they were experiencing adrenal insufficiency, especially due to the abrupt ending of their 30mg/day dose. However, without further tests such as blood work it is hard to confirm or refute this diagnosis. Something to consider as well is that corticosteroid use, and withdrawal are dose and duration dependent. Prolonged daily steroid use is a risk factor, however a short 5-day course of Prednisone for asthma or COPD, which is very commonly prescribed, would not typically be problematic when the course stops.
We would also like to highlight our Case Review Request Form. If you are looking for a specific outcome of a patient that you transported, this may be a better option in the future.
Referring to the patient you recently encountered, it is feasible that they were experiencing adrenal insufficiency, especially due to the abrupt ending of their 30mg/day dose. However, without further tests such as blood work it is hard to confirm or refute this diagnosis. Something to consider as well is that corticosteroid use, and withdrawal are dose and duration dependent. Prolonged daily steroid use is a risk factor, however a short 5-day course of Prednisone for asthma or COPD, which is very commonly prescribed, would not typically be problematic when the course stops.
We would also like to highlight our Case Review Request Form. If you are looking for a specific outcome of a patient that you transported, this may be a better option in the future.
References
https://www.uptodate.com/contents/glucocorticoid-withdrawal?search=steroid%20withdrawal&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1
https://www.uptodate.com/contents/clinical-manifestations-of-adrenal-insufficiency-in-adults?search=steroid%20withdrawal&topicRef=7983&source=see_link
https://www.uptodate.com/contents/clinical-manifestations-of-adrenal-insufficiency-in-adults?search=steroid%20withdrawal&topicRef=7983&source=see_link