Primary adrenal insufficiency (AI) is more common than secondary (pituitary) AI. Commonest cause of AI in India still would be tuberculosis; however, autoimmune disease, fungal infection, metastasis and drug-related are other common causes.

How is adrenal insufficiency following steroid withdrawal treated?

There is a paucity of evidence to support any particular regimen of glucocorticoid tapering. Short-term glucocorticoid therapy (up to 3 weeks) can usually be stopped without a taper. In patients who have taken a glucocorticoid for a longer time, have a Cushingoid appearance or received evening dosing, a regimen which is largely based upon experience and considers the patient’s general health status, stability of the disease being treated, and the drug regimen that has been used, is advised. The usual endpoints are the patient’s signs and symptoms.

The goal of tapering is to use a rate of change that will prevent both recurrent activity of the underlying disease and symptoms of cortisol deficiency due to persistent hypothalamus-pituitary-adrenal (HPA) axis suppression. It is generally better to aim for a relatively stable decrement of 5-10% every 1-4 weeks, while accommodating convenience and individual patient  response.

Is fludrocortisone required in every case of adrenal insufficiency?

Most patients with primary AI eventually require mineralocorticoid replacement to prevent sodium loss, intravascular volume depletion and hyperkalemia. Mineralocorticoid replacement is rarely required in patients with secondary AI because adrenocorticotropic hormone (ACTH) is not the main physiological regulator of aldosterone release.