Glucocorticoid-Induced Adrenal Insufficiency rare after Prednisolone Cessation in polymyalgia rheumatica and giant cell arteritis: JAMA
Researchers have discovered in a new study that glucocorticoid-induced adrenal insufficiency (GIAI) was rare (1.9%) in patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) two or more weeks after stopping prednisolone, based on the 250 μg short corticotropin test . However, one-third of patients had symptoms of adrenal insufficiency despite normal SST results and showed lower basal cortisol levels. These findings highlight the need for better diagnostic and therapeutic tools, as well as future randomized clinical trials incorporating both physician- and patient-reported outcomes. The study was conducted by Simon B. and fellow researchers.
This cross-sectional multicenter study was performed at three hospitals in Denmark as part of an ongoing randomized clinical trial. Data on clinical, demographic, and treatment characteristics were obtained at baseline between March 2021 and March 2024. All 267 participants had a diagnosis of PMR and/or GCA and had their axes evaluated a median of 39 days after pre-planned withdrawal of prednisolone. Participants were taking prednisolone at baseline for a median duration of 13 months.
The primary outcome was the prevalence of GIAI, evaluated using a short corticotropin stimulation test (SST) (0.25 mg). Although there is no established threshold for adrenal insufficiency in this situation, participants with a baseline cortisol level <420 nmol/L at 30 minutes after the SST were defined to have adrenal insufficiency. The second outcome was to evaluate if participants had GIAI and were symptomatic using a questionnaire assessing quality of life in addisonian patients (AddiQol-30). Finally, both body composition and muscle function were evaluated, as these factors may be more direct measures of health than biochemistry findings.
Key Findings
• Prevalence of GIAI: Only 5 of the 267 patients met criteria for GIAI (1.9%; 95% CI, 0.8%-4.3%), suggesting GIAI is rare after steroid withdrawal.
• Prevalence of symptoms: Despite low prevalence of GIAI, there were 75 patients (34%; 95% CI, 28%-41%) that were symptomatic, identified via an AddiQol-30 score <85 (in this cohort, the AddiQoL-30 score is a measure of symptomology and health status).
• Cortisol levels: Symptomatic participants had significantly lower baseline cortisol levels compared with asymptomatic participants (263 nmol/L; 95% CI, 242-283 nmol/L vs 309 nmol/L; 95% CI, 295-324 nmol/L, p<0 .001).
• Associated factors: Symptoms of adrenal insufficiency were more prevalent in women (PR, 1.68; 95% CI, 1.13-2.51) and were associated with increased body fat percentage (PR, 2.33; 95% CI, 1.21-4.50), reduced hand grip strength (PR, 2.71; 95% CI, 1.44-5.10), and a low Short Physical Performance Battery score (PR, 2.78; 95% CI, 1.42-5.42).
The current study suggests that GIAI is uncommon among patients who have PMR or GCA after stopping prednisolone and lends credence to a selective strategy of evaluating persons with symptoms rather than universal testing. However, the high frequency of symptoms consistent with adrenal insufficiency does present clinical difficulties regarding steroid cessation and emphasizes the necessity of research to enhance patient management in the future.
Reference:
Hansen SB, Dreyer AF, Jørgensen NT, et al. Changes in Adrenal Function and Insufficiency Symptoms After Cessation of Prednisolone. JAMA Netw Open. 2025;8(3):e251029. doi:10.1001/jamanetworkopen.2025.1029
