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 30 adults in the U.S. is on these drugs at any time, and many don’t know the risks of quitting cold turkey. Even short courses-like a two-week steroid pack for a bad sinus infection-can mess with your body’s natural cortisol production. When you stop, your adrenal glands, which have been shut down by the medication, can’t snap back fast enough. The result? Fatigue so deep it feels like your bones are made of lead, nausea, low blood pressure, and sometimes, shock.

Why Your Body Can’t Handle a Sudden Stop

Your body makes cortisol naturally. It’s the hormone that keeps your blood sugar stable, controls inflammation, and helps you respond to stress-like an infection, injury, or even emotional pressure. When you take synthetic corticosteroids for weeks or months, your brain thinks, “We’ve got plenty of cortisol already,” and shuts off the signal to your adrenal glands. Over time, those glands shrink. They forget how to make cortisol on their own.

This isn’t just a problem for people on high doses. A 2023 study in Endocrine Abstracts showed that even low-dose prednisone (less than 5 mg daily) for just four weeks can suppress your adrenal axis. That means someone taking a low-dose steroid for allergies or mild asthma could still be at risk if they stop abruptly. The old rule-that only long-term, high-dose users are at risk-is outdated. The truth is, anyone who’s been on steroids for more than a few weeks needs to taper slowly.

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

Symptoms don’t show up right away. They creep in 24 to 72 hours after your last pill. At first, it’s easy to brush them off:

• Extreme fatigue-so bad you can’t get out of bed
• Loss of appetite and unexplained weight loss
• Nausea, vomiting, or stomach pain
• Muscle weakness or aching joints
• Mood changes: irritability, depression, or brain fog

These look like the flu. Or burnout. Or depression. That’s why so many people wait weeks before getting help. A 2024 analysis of patient forums found that 68% of people had their symptoms misdiagnosed as something else-viral illness, anxiety, or even a urinary tract infection. One woman in her 40s was treated for a UTI for six weeks after stopping dexamethasone. She ended up in the ER in adrenal crisis, her blood pressure crashing, her mind cloudy. Only when her doctor checked her cortisol levels did they realize she was dying from lack of her body’s own hormone.

When it gets worse, you enter adrenal crisis:

• Severe drop in blood pressure
• Dehydration
• Confusion, dizziness, fainting
• Coma or death if untreated

Mortality rates hit 6% in hospitalized cases. That’s why this isn’t something you wait on.

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 to tell the adrenals to work.
• Tertiary: The hypothalamus stops making CRH, which normally tells the pituitary to act. This is the kind caused by steroid withdrawal.

Tertiary is the most common in people coming off steroids. The key difference? In primary adrenal failure, your ACTH levels are sky-high because your body is screaming for cortisol. In tertiary, ACTH is low because your brain turned it off. That’s why a simple blood test for cortisol and ACTH is critical-if your cortisol is under 5 μg/dL and your ACTH is low, it’s likely steroid-induced.

How Doctors Diagnose It

If you’ve been on steroids and now feel terrible, your doctor should check:

• **Morning serum cortisol**-drawn before 9 a.m. Levels below 5 μg/dL are a red flag.
• **ACTH stimulation test**-this is the gold standard. You get a shot of synthetic ACTH, and your cortisol is measured 30 and 60 minutes later. If your cortisol doesn’t rise above 18 μg/dL, your adrenals aren’t responding.

Some patients with withdrawal symptoms have normal cortisol levels at rest but fail the stimulation test. That’s why testing isn’t optional if you’ve been on steroids for more than four weeks.

How to Taper Safely-And Why There’s No One-Size-Fits-All

There’s no perfect tapering schedule. But here’s what major guidelines agree on:

• If you were on more than 20 mg of prednisone daily for over three weeks-get tested before stopping.
• 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 were on steroids for more than six months, slow it down even more-sometimes over 3-6 months.

The European Society of Endocrinology recommends a standard 4-8 week taper. The Endocrine Society says tailor it to you: your age, other illnesses, how long you were on steroids, and whether you’ve had adrenal issues before.

Here’s the hard truth: even if you follow the taper perfectly, some people still develop adrenal insufficiency. That’s why education matters more than protocol.

What You Need to Do Right Now

If you’re on steroids-or just stopped them-here’s what you must do:

• Never stop abruptly. Even if you feel fine. Even if your doctor didn’t mention it.
• Ask for a written taper plan. Don’t rely on memory. Get it in writing.
• Carry an emergency steroid card. The FDA has required this on all systemic steroid packaging since 2021. It tells emergency staff you’re at risk.
• Get trained on emergency hydrocortisone injections. If you feel your symptoms worsening-nausea, dizziness, low blood pressure-give yourself 100 mg of hydrocortisone IM right away. Then call 911. This saves lives.
• Wear a medical alert bracelet. It’s not just for diabetics. If you’ve been on steroids for more than four weeks, this is essential.

A 2023 Mayo Clinic study found that patients who had a written action plan and injection training had 79% better outcomes. They didn’t end up in the ER. They didn’t go into crisis. They knew what to do.

What to Do If You Think You’re in Crisis

Adrenal crisis is a medical emergency. If you have:

• Severe vomiting or diarrhea
• Low blood pressure or fainting
• Confusion or loss of consciousness

-don’t wait. Give yourself an emergency injection of hydrocortisone (100 mg) immediately. Then go to the ER. Do not drive yourself. Call 911.

In the hospital, you’ll get IV hydrocortisone (100 mg bolus, then 200 mg over 24 hours). Blood pressure usually improves within 30-60 minutes. But delay means death.

The Bigger Picture: Why This Is Getting Worse

Corticosteroid prescriptions have jumped 23% since 2015. More people are getting them for asthma, arthritis, autoimmune diseases, even long COVID. But awareness hasn’t kept up. A 2023 study in JAMA Internal Medicine found 47% of patients didn’t follow their tapering plan-because they forgot, didn’t understand, or were scared of side effects.

The economic cost is heavy: each adrenal crisis hospitalization averages $14,250. And the human cost? Lost work, missed family events, trauma from nearly dying.

But there’s hope. AI tools are now being tested to predict who’s at risk by analyzing electronic health records. Point-of-care cortisol tests are in trials-they’ll give results in 15 minutes, right in the doctor’s office. And by 2030, experts predict a 30% drop in adrenal crises thanks to better education and tools.

Final Takeaway

Corticosteroids save lives. But they can also kill if stopped the wrong way. You don’t need to be on them for years to be at risk. You don’t need a high dose. The danger is real, silent, and often missed.

If you’ve taken steroids in the last six months and feel off-fatigued, nauseous, weak-don’t assume it’s stress or a virus. Ask your doctor: “Could this be adrenal insufficiency?”

And if you’re still on them? Ask for a taper plan. Ask for the emergency injection. Ask for the medical alert bracelet. Your life might depend on it.