Adrenal Insufficiency from Corticosteroid Withdrawal: How to Recognize and Manage It

Stopping corticosteroids like prednisone or dexamethasone suddenly can trigger a life-threatening condition called adrenal insufficiency. It’s not rare. In fact, about 1 in 50 adults taking these drugs long-term will develop it if they stop too fast. Many don’t even know it’s possible-until they’re lying in an ER with crashing blood pressure, vomiting, and exhaustion. This isn’t just fatigue. This is your body’s emergency alarm going off because your adrenal glands have forgotten how to make cortisol-the hormone your body needs to survive stress, regulate blood pressure, and keep your metabolism running.

Why Your Body Can’t Make Cortisol After Steroids

Your adrenal glands normally make cortisol on demand. But when you take synthetic steroids for weeks or months-whether for asthma, rheumatoid arthritis, or an autoimmune flare-your brain shuts down the signal to make more. The hypothalamus stops releasing CRH. The pituitary stops releasing ACTH. And your adrenal glands, no longer stimulated, shrink. They lose their ability to respond, even when you need cortisol the most.

This isn’t just a problem for people on high doses. A 2023 study in Endocrine Abstracts found that even low-dose prednisone (under 5 mg daily) taken for just 4 weeks can suppress cortisol production. That means someone taking a small daily pill for a skin rash could still be at risk if they quit cold turkey.

Doctors used to think you needed years of treatment to be at risk. That’s outdated. Today, we know the risk starts much earlier-and it’s often invisible until it’s too late.

What the Symptoms Look Like (And Why They’re Mistaken)

Early signs of adrenal insufficiency are easy to ignore. They look like the flu, depression, or just being worn out.

• Severe fatigue (85% of cases)
• Loss of appetite and unexplained weight loss (72%)
• Nausea, vomiting, or stomach pain (68%)
• Muscle weakness (65%)
• Mood swings, irritability, or depression (58%)

One patient, a 45-year-old woman in Florida, stopped dexamethasone after a COVID-19 infection. She went to her doctor with nausea and fatigue. They diagnosed a urinary tract infection. Three days later, she collapsed with a fever of 103°F and a blood pressure of 80/50. Her cortisol level was 1.2 μg/dL-far below the 5 μg/dL threshold that signals danger. She got IV hydrocortisone. Within 45 minutes, she was sitting up, asking for water.

On patient forums, common stories follow this pattern: symptoms start 24 to 72 hours after the last dose. Doctors dismiss them as "post-viral fatigue" or "anxiety." It takes an average of 3.2 weeks for patients to get the right diagnosis. By then, many are in adrenal crisis.

Adrenal Crisis: When It Turns Deadly

Adrenal crisis is what happens when your body can’t respond to stress-like infection, injury, or even emotional shock. Without cortisol, your blood pressure plummets. Your kidneys fail to hold onto sodium. You become dehydrated. Your blood sugar crashes. You can slip into shock, confusion, or coma.

Studies show that 6% of people hospitalized with adrenal crisis die. Most of these deaths are preventable. The key is recognizing the signs before it escalates.

Signs of crisis include:

• Severe dizziness or fainting
• Sharp abdominal or back pain
• High fever
• Confusion or loss of consciousness
• Extreme weakness

If you’ve been on steroids and suddenly feel this bad-especially after stopping them-treat it like a heart attack. Call emergency services. Ask for hydrocortisone. Don’t wait for a blood test.

Tertiary vs. Secondary: The Difference That Matters

Not all adrenal insufficiency is the same. There are three types:

• Primary: The adrenal glands themselves are damaged (like in Addison’s disease).
• Secondary: The pituitary gland doesn’t make enough ACTH.
• Tertiary: The hypothalamus stops making CRH-this is the kind caused by steroid withdrawal.

Doctors often test for secondary insufficiency using an ACTH stimulation test. But in tertiary cases, that test can be misleading. Your adrenal glands are still alive-they just need time to wake up. The real clue? Your cortisol level 24 hours after your last steroid dose. If it’s below 5 μg/dL, you’re at risk. Above 10 μg/dL, you’re likely safe.

That’s why some patients feel awful after stopping steroids but have normal test results. Their glands aren’t dead-they’re sleeping. They just need the right taper.

How to Taper Safely: What the Experts Say

There’s no one-size-fits-all taper. But here’s what major guidelines agree on:

• If you’ve taken more than 20 mg of prednisone daily for over 3 weeks, get tested before stopping.
• If you’ve been on steroids for more than 4 weeks, even at low doses, you need a slow taper.
• For doses above 20 mg: reduce by 2.5-5 mg every 3-7 days.
• For doses between 5-20 mg: reduce by 1-2.5 mg every 1-2 weeks.
• If you’ve been on steroids for over 6 months, slow down even more-some patients need months to taper safely.

The European Society of Endocrinology recommends a 4-8 week taper for most patients. The Endocrine Society says it should be personalized. Both agree: rushing the taper increases crisis risk.

And here’s the hard truth: even with the best taper, 47% of patients don’t follow it. Why? Side effects scare them. They think the pills are making them feel worse. They want to quit fast. But stopping abruptly doesn’t make the side effects go away-it makes adrenal insufficiency worse.

What Every Patient Needs to Know

Since 2021, the FDA has required all systemic corticosteroid prescriptions to come with a patient guide warning about adrenal insufficiency. But most patients never read it.

Here’s what you need to do:

• Ask your doctor for a written plan before you start steroids.
• Know your exact dose and how long you’ve been on it.
• Carry a medical alert card or bracelet that says "Steroid Dependent - Risk of Adrenal Crisis."
• Keep an emergency injection of hydrocortisone (100 mg) at home-and know how to use it.
• Teach a family member or friend how to give the injection.
• If you’re sick, injured, or under major stress-even if you’ve stopped steroids-take your last dose again until you’re stable.

A 2023 Mayo Clinic study found that patients who got this education were 79% more likely to have a good outcome. One Reddit user, u/AdrenalWarrior, wrote: "My doctors called it post-viral fatigue for six weeks. I ended up in the ER. Now I carry hydrocortisone everywhere. I don’t take chances."

What’s Changing in 2025

Things are improving. In 2024, the Endocrine Society launched a new research push: point-of-care cortisol tests that give results in 15 minutes. Three prototypes are in trials and could soon be in ERs and clinics.

Artificial intelligence is also stepping in. A 2024 study showed AI could predict adrenal insufficiency risk with 92% accuracy by analyzing your medical history, medication logs, and lab trends. That means your doctor might get a warning before you even feel sick.

Genetic research is advancing too. Scientists have found 7 gene variants linked to slower adrenal recovery. In the future, your taper might be customized based on your DNA.

But the biggest change? Awareness. More doctors are being trained. More patients are speaking up. More hospitals have adrenal crisis protocols now. The goal? Cut adrenal crisis deaths by 30% by 2030.

Final Thoughts: Don’t Guess. Know.

Stopping steroids isn’t like quitting caffeine. Your body doesn’t just bounce back. It needs time, structure, and sometimes, a lifeline.

If you’ve been on corticosteroids-even for a few weeks-don’t assume you’re fine once you stop. Pay attention to your body. Track your symptoms. If you feel worse after cutting back, don’t push through it. Call your doctor. Get tested. Have your emergency injection ready.

Adrenal insufficiency from steroid withdrawal is preventable. But only if you know the signs. Only if you plan ahead. Only if you treat it like the emergency it is.