Identifying patients at risk of adrenal suppression (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

See Society for Endocrinology (SFE): Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely for information on identifying individuals at risk of iatrogenic adrenal suppression and who should be provided with a asteroid emergency card. 

There is significant variability in the susceptibility to adrenal suppression, for example, 10% of individuals on high dose inhaled glucocorticoids will have evidence of adrenal suppression.

The following patient groups are at higher risk of adrenal suppression:

  • Individuals on inhaled glucocorticoids or an intra-articular glucocorticoid injection, co-prescribed CYP3A4 inhibitors such as antifungals and protease inhibitors, will be at high risk.
  • Patients on high dose inhaled glucocorticoids plus other glucocorticoids such as nasal or high dose topical steroids.
  • If a patient is Cushingoid due to exogenous steroids.
  • Individuals receiving 3 or more intra-articular steroid injections within 12 months, including for 12 months thereafter.  

A high degree of clinical suspicion is required to prevent the potentially life threatening consequences of an adrenal crisis. The following tables include information on glucocorticoid dose equivalence and doses risking adrenal suppression. The tables are adapted from the SFE guidance.

Table 1:

Long-term glucocorticoids

  • 4 weeks or longer

Dose risking adrenal suppression (*)
Beclometasone 625 microgram per day or more
Betamethasone 750 microgram per day or more
Budesonide 1.5mg per day or more (***)
Deflazacort 6mg per day or more
Dexamethasone 500 microgram per day or more (**)
Hydrocortisone 15mg per day or more (**)
Methylprednisolone 4mg per day or more
Prednisone 5mg per day or more
Prednisolone 5mg per day or more

(*) dose equivalent from BNF EXCEPT:
(**) where dose reflects that described in the guideline by (Simpson et al 2020)
(***) based on best estimate

Table 2:

Short-term glucocorticoids

  • One week course or longer
  • AND has been on long-term course within the last year
  • OR has regular need for repeated courses (3 or more courses within past 12 months)

Dose risking adrenal suppression(*)
Beclometasone 5mg
Betamethasone 6mg per day or more
Budesonide 12mg (***)
Deflazacort 48mg per day or more
Dexamethasone 4mg per day or more (**)
Hydrocortisone 120mg per day or more (**)
Methylprednisolone 32mg per day or more
Prednisone 40mg per day or more
Prednisolone 40mg per day or more

(*) dose equivalent from BNF EXCEPT:
(**) where dose reflects that given associated Guidance (Simpson et al 2020)
(***) based on best estimate

Table 3: 

Inhaled glucocorticoid

Dose risking adrenal suppression(*)
Beclometasone (as non-proprietary, Clenil, Easihaler, or Soprobec) More than 1000 microgram per day
Beclometasone (as Qvar, Kelhale or Fostair) More than 500 microgram per day (check if using combination inhaler and MART regimen)
Budesonide More than 1000 microgram per day (check if using combination inhaler and MART regimen)
Ciclesonide More than 480 microgram per day
Fluticasone propionate More than 500 microgram per day
Fluticasone furoate (as Trelegy and Relvar) Fluticasone furoate (as Trelegy and Relvar)
Mometasone More than 800 microgram per day

(*) dose equivalent from NICE Inhaled corticosteroid doses for NICE asthma guideline (2018)

Peri-operative guidance for patients at risk of adrenal insufficiency.

Peri-operative guidance for patients with or at risk of adrenal insufficiency (Guidelines)

Patient information

Abbreviations

  • SFE: Society for Endocrinology 

Editorial Information

Last reviewed: 28/08/2025

Next review date: 31/08/2028

Author(s): Endocrinology.

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): A Mehta, Surgical Lead Pharmacist.

Document Id: TAM707