Prednisolone and Adrenal Insufficiency
Date issued: July 2021
Review date: July 2023
Ref: A-472
PDF: Prednisolone and Adrenal Insufficiency final July 2021.pdf [pdf] 830KB
This leaflet contains information about the importance of your steroids, steroid sick day rules, and weaning your steroids. Please read it carefully and raise any questions you may have.
What is prednisolone?
Prednisolone is a type of medicine known as a corticosteroid. Corticosteroids are copies of hormones your body produces naturally. Prednisolone has potent anti-inflammatory effects and is used to treat a wide range of health problems, including asthma.
Prednisolone is a prescription only medication and must be taken according to directions from your medical team.
Long-term use or high doses of prednisolone can lead to adverse side-effects. For this reason, every effort will be made within the management of your asthma to reduce the amount of prednisolone you take.
If you have been on a long-term maintenance dose of prednisolone, or have had an extended course of treatment, it is essential that the drug is reduced in the proper way in order to prevent symptoms of adrenal insufficiency. You will therefore be given a plan of how to wean your prednisolone.
Why can I not stop taking prednisolone suddenly?
Prednisolone is a synthetic steroid and works by mimicking the effects of cortisol. Cortisol is a steroid hormone naturally made by your adrenal glands and is responsible for regulating a number of processes throughout the body, including metabolism and immune responses. It is especially important at times when the body experiences intense stress (eg. surgery, trauma, infection).
Whilst it is safe to take short rescue courses of prednisolone and stop abruptly after the prescribed duration (usually 5-7 days), if you take prednisolone for more than a few weeks the natural production of cortisol by your adrenal glands will decrease. If you stop prednisolone suddenly and before natural production of cortisol is restored, withdrawal symptoms can occur.
This can also occur if high dose inhaled steroids are stopped suddenly.
The risk of adrenal insufficiency can last for 12 months after stopping steroid treatment.
The presence of synthetic steroids in the blood can cause the adrenal glands to reduce or stop producing cortisol, and go into a ‘sleep-like’ state. This is not a problem as long as synthetic steroids continue to be taken at the correct dose. However, if they are stopped suddenly the adrenal glands may not be able to produce enough cortisol to meet your body’s needs. This is known as adrenal insufficiency. Many people taking long-term steroids who have adrenal insufficiency will never have a problem from it, unless steroids are stopped abruptly or weaned too quickly.
Risk factors for adrenal insufficiency during periods of illness can include…
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Taking 5mg or more of prednisolone, for 4 weeks or longer.
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Regular rescue courses of prednisolone (for example, 3 or more rescue courses over 6-12 months).
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Taking high dose inhaled steroids.
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Total exposure if taking steroids by a combination of routes or for different conditions (e.g. oral, nasal, inhaled, joint injection, topical/skin, eye drops, rectal).
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Taking certain other medications (e.g. antifungal) medications plus steroids.
Clinical symptoms of adrenal insufficiency usually develop gradually and progress slowly, so sometimes go unnoticed. Prolonged lack of cortisol can lead to a life-threatening adrenal crisis.
Synthetic steroid withdrawal symptoms can include…
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Joint pain
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Muscle pain
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Fatigue / exhaustion
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Low blood pressure
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Nausea
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Vomiting
If you experience persisting symptoms like these, please discuss with your GP or the Asthma Team
NEVER skip a steroid dose and NEVER stop taking steroids abruptly. If reducing your steroid dose is causing your asthma symptoms to worsen, please seek medical advice before reducing further.
Steroid Sick Day Rules
If you have been taking 5mg or more of prednisolone, for 4 weeks or longer, it is possible that you have developed adrenal insufficiency. Many people taking long-term steroids who have adrenal insufficiency will never have a problem from it. However, if you happen to become ill from some other cause, you need to know how to adjust your steroid dose. This ensures that your body gets the steroid “boost” it needs to help you get over the new illness.
Sick day rule 1: If you are ill enough to need to stay in bed, OR if you have an infection that makes you unwell and you have been given antibiotics, increase your usual steroid dose for the time that you are unwell.
NB. This advice is for illnesses that aren’t directly related to your asthma. If you are having an asthma attack, you will need to increase your steroids to 40mg/day for a minimum of 5 days as per your asthma self-management plan, and then drop back down to your usual daily dose as per your normal regimen.
Sick day rule 2: If you might not absorb your steroid tablets, or you are very ill, you will need an injection of steroid that same day AND will need medical advice about when to return to your normal dose.
This rule may apply if, for example, you have severe diarrhoea or vomiting that lasts a day or more, have a major injury illness, or major surgery, or during childbirth.
Seek medical advice urgently that day including 111 or ED/999 if it’s an emergency
Steroid weaning plan
If synthetic steroids such as prednisolone are no longer needed as part of your maintenance asthma treatment, doses should be gradually reduced to ensure the adrenal glands ‘wake up’ again and start producing sufficient cortisol. You will be given specific instructions on how to do this. NB: You should also not suddenly stop or reduce your inhaled steroids without a plan.
Your steroid weaning plan
Please note, when you first start to decrease your prednisolone, you may feel achy or tired. This is quite common. However, if these symptoms do not resolve over the course of 7 days, please contact us to review your plan.
What happens if I develop signs of adrenal insufficiency?
If you display any signs or symptoms of adrenal insufficiency during your steroid wean, we will immediately ask you to increase your prednisolone back to at least 4mg / day. You will then be referred for a Short Synacthen Test. A Short Synacthen Test is used to assess how much of the natural steroid hormone cortisol your body is producing. It involves taking some blood samples and being given an intravenous injection. If this test is required, you will be given more detailed information of what to expect.
If you are on oral steroids or high dose inhaled steroids you should always carry a steroid alert card with you.
In case of an emergency, call 111 or 999
Useful information about asthma can be found at Asthma UK
TEL: 0300 222 5800 (Monday to Friday, 9am to 5pm)
WEB: www.asthma.org.uk
References:
https://www.endocrinology.org/adrenal-crisis
https://www.leedsth.nhs.uk/assets/be1c37f891/Instructions_For-online-distribution_Final-Design2.pdf
https://www.verywellhealth.com/does-prednisone-tapering-minimize-withdrawal-190242
