Question: I have been trying to taper my replacement dose of Cortisone following adrenal surgery, and have ended up in the Emergency Room several times due to adrenal insufficiency. I have been told that for my adrenal gland to start working again, I need to be this low. Is that true? What tapering protocol would you recommend and what tests should be performed during the tapering phase?

Answer: These are very good questions. Tapering of Cortisone following either bilateral adrenalectomy or a single Cortisol secreting adrenal tumor, especially when it is successful, results in profound hypothalamic pituitary adrenal suppression. The reawakening of this axis may take six to nine months, sometimes longer. In the interim, patients need to be replaced with Glucocorticoid therapy. There is an additional confounding problem and that is when you have Cushing’s, your body gets used to higher doses of Glucocorticoids coids and these doses need to be continued above replacement doses immediately after surgery and then slowly tapered. Right after surgery we replace with Hydrocortisone 60 to 80 mg a day for two weeks and start a taper, diminishing 10 to 20 mg every 10 to 14 days, until you are down to physiologic, which is in the neighborhood of 15 to 20 mg per day. We like to do a Cortrosyn stimulation test every two months to plot the hypothalamic pituitary adrenal recovery. Morning plasma cortisol before taking oral cortisone may also be useful, but we prefer the cortrosyn test. Once the Cortrosyn stimulation test is in the normal range, then Hydrocortisone can be safely discontinued, or tapered to a lower dose, then discontinued.

We do not suggest longer acting steroids, such as Prednisone, which might further prolong pituitary adrenal suppression. The use of Hydrocortisone alone is what is suggested immediately after successful surgery. There is not only a need for Glucocorticoid replacement to avoid adrenal insufficiency; there is a withdrawal from the high endogenous levels. When you withdraw from steroids, even though you are in the normal range for replacement, you will have symptoms of steroid withdrawal which include fatigue, depression, and muscle and joint aching. This is why endocrinologists will tell you that you will feel worse from steroid withdrawal after successful surgery than you felt with the Cushing’s syndrome. The steroid withdrawal symptoms can last up to two years and they are again, fatigue, depression, and aching.

There is no good evidence that taking less steroid, or no steroid, accelerates the hypothalamic pituitary adrenal axis recovery. Certainly you cannot use high doses without continuing to suppress the pituitary adrenal axis, but in general, completely stopping steroids is not suggested, since adrenal insufficiency would be predicted under those sets of circumstances and also aggravation of severe withdrawal symptomatology.

In summary, it is important to treat adrenal insufficiency symptoms of lightheadedness and nausea, and also distinguish that from steroid withdrawal symptoms, which are fatigue, depression, and achiness, even though you might be protected from adrenal insufficiency.

By Dr. David Cook MD (February, 1999)