A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy

Table 8 Screening recommendations for AS[91]

When to Screen?
• Patient has received systemic corticosteroids for:
> 2 consecutive weeks or >3 cumulative weeks in the last 6 months
• Patient has persistent symptoms of AS:
– Weakness/fatigue, malaise, nausea, vomiting, diarrhea, abdominal pain, headache (usually in the morning), poor weight gain and/or growth in children, myalgia, arthralgia, psychiatric symptoms, hypotension, hypoglycemia
How to Screen?
• Measure early morning cortisol^‡
– GC dose tapered to physiologic dose prior to test
– No oral GCs the evening and morning prior to the test^†
– Must be completed by 8:00 am or earlier
– Fasting not required
• If morning cortisol is normal but patient has symptoms of AS, perform low-dose ACTH stimulation test^‡ to confirm diagnosis:
– 1 μg of cosyntropin; cortisol levels taken at 0, 15–20 and 30 minutes**
– Peak cortisol < 500 nmol/L = AS (peak >500 nmol/L is normal)
When to be Concerned?
• Early morning cortisol < 85 nmol/L = diagnosis of AS
• Early morning cortisol < laboratory normal = possible AS; consider endocrinology referral for confirmation of diagnosis

Modified from Ahmet et al., 2011 [91].
AS adrenal suppression, ACTH adrenocorticotropic hormone, GCs glucocorticoids.
*Symptoms of adrenal crisis require emergent management.
^†Patients must be switched to hydrocortisone for this to apply. If the patient is on a GC with a longer half-life (e.g., dexamethasone), then morning cortisol will remain suppressed due to the medication 24 hours after a dose.
^**Ideally, GCs should be withdrawn prior to this test to avoid ongoing HPA suppression or falsely elevated cortisol levels in the case of GCs that are detected by the cortisol assay. In patients believed to be at high risk of adrenal crisis without GC treatment, dexamethasone can be used. Dexamethasone would be associated with suppression of the baseline cortisol level, but ACTH-stimulated cortisol levels should reflect endogenous production since dexamethasone typically does not cross-react with cortisol assays.
^‡Exogenous estrogen therapy increases serum cortisol; therefore, cortisol levels will not be reliable in the setting of estrogen use.