SAT-450 - The Hidden Cost of "Short Steroid Bursts": A Case of Glucocorticoid Withdrawal Syndrome

Introduction:
Glucocorticoids are widely prescribed in outpatient and urgent care settings. Repeated supraphysiologic glucocorticoid exposure can suppress the HPA axis, leading to withdrawal symptoms that mimic adrenal insufficiency. GWS is an often-overlooked condition causing nonspecific systemic and neuropsychiatric effects during or after steroid tapering.

Case Presentation:
A 25-year-old woman with asthma, anxiety, depression, trigeminal neuralgia, and suspected lupus was evaluated for possible adrenal insufficiency. Over the past year, she received multiple high-dose glucocorticoid courses for asthma. She took prednisone 20 mg daily for rash and joint pain, tapered to 10 mg, and remained stable until reduced to 7.5 mg, when fatigue, weakness, and mood changes developed. Prednisone was increased to 10 mg and tapered slowly by 1 mg/week. On 10 mg, morning cortisol was 3.8 µg/dL with ACTH < 5 pg/mL, confirming exogenous suppression. During rapid tapering, fatigue and myalgias occurred, but during slower tapering she was asymptomatic.Vital signs were consistently normal, and basic metabolic panels showed normal electrolytes. In the absence of clinical features such as hypotension,hyperkalemia, or hyponatremia, her presentation supported GWS rather than adrenal insufficiency. She was advised to continue gradual tapering and reassess HPA function at physiologic dosing.

Discussion:
GWS represents physical dependence after prolonged or repeated steroid exposure. Even at supraphysiologic doses, unlike adrenal insufficiency, GWS symptoms arise with normal hemodynamics. It results from suppression of corticotropin-releasing hormone, proopiomelanocortin, and dysregulation of cytokine and neurotransmitter systems. Repeated steroid “bursts,” often given in urgent care without tapering and patient education, cause cumulative HPA suppression and withdrawal symptoms. Recognizing GWS prevents misdiagnosis and unnecessary steroid escalation that can delay adrenal recovery.

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