🔄 Steroid-Induced Adrenal Fatigue: When Support Prevents Recovery

Understanding Adrenal Insufficiency Through the ERM and Stress Adaptation Lens

In our fast-paced world, stress is constant—so our bodies rely on a finely tuned stress-response system to keep us going. At the center of this system is cortisol, a hormone produced by the adrenal glands that helps us maintain blood pressure, regulate inflammation, and mobilize energy when we need it most.

A recent review in JAMA (June 2025) underscores just how critical this system is—and how vulnerable it becomes, especially when glucocorticoids (steroids like prednisone or dexamethasone) are used to control inflammation. While these medications are powerful tools in acute care, their prolonged use can lead to a silent collapse of resilience, a condition known as glucocorticoid-induced adrenal insufficiency (AI).

🚨 Steroids: Suppressing Symptoms, Blocking Recovery

Steroids help manage stress-related damage and inflammation. But they don’t heal—they suppress. When given in high doses or over long periods, they override the body’s natural cortisol rhythm, keeping the system in a prolonged, externally managed stress response.

What’s the problem?

• These medications reduce the body’s own cortisol production through negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis.

• More critically, they interrupt the body’s innate recovery cycle—the phase where nutrients are reabsorbed, tissue is rebuilt, and the system rebalances.

Over time, this leaves the system depleted:

• Nutrients like zinc, selenium, and B vitamins are consumed without replenishment.

• Anabolic hormones like DHEA drop.

• Mitochondrial and adrenal reserve quietly shrink.

So when the external steroids are reduced—or abruptly stopped—the body may no longer have the internal capacity to mount a response. What follows is fatigue, low mood, poor recovery, and, in severe cases, adrenal crisis: a medical emergency marked by shock, low blood pressure, and electrolyte imbalances.

🧠 ERM: A Framework for Understanding Subclinical Collapse

This pattern isn’t just about hormones—it’s about energy availability and allocation. That’s where the concept of Exposure-Related Malnutrition (ERM) offers new clarity.

ERM describes a state where chronic stress, environmental triggers, or therapeutic suppression lead to a mismatch between demand and supply. Over time, the body starts prioritizing immediate survival at the expense of long-term repair.

In the ERM model:

• Stage 1: The body adapts by shifting resources away from growth and toward inflammation control.

• Stage 2: Adaptation continues, but at a cost—nutrient stores dwindle, anabolic signaling drops, and stress systems (like the adrenals) begin to fatigue.

• Stage 3: The system decompensates. Even small stressors can provoke a crash.

Steroid-induced adrenal insufficiency fits this exactly. What looks like a hormonal problem is actually a bioenergetic one—a sign of deeper system fatigue.

🔍 The Early Warning Signs

Before collapse, the warning signs are subtle—but important:

• Fatigue that doesn't improve with rest

• Poor recovery from illness or exercise

• Orthostatic dizziness or salt cravings

• Brain fog or mood instability

• Need for constant stimulation (caffeine, carbs) just to get through the day

These symptoms may not show up in standard labs, but they reflect a functional deficit in resilience—what ERM calls the "energy cost of adaptation."

💡 What Can Be Done?

1. Recognize long-term steroid use as a metabolic stressor, not just a treatment.

2. Assess functional reserve before tapering steroids—using early-morning cortisol, DHEAS, and symptom patterns.

3. Support recovery through gradual tapering, nutrient repletion (e.g., magnesium, vitamin C, B5, zinc), and lifestyle interventions like circadian alignment and stress reduction.

4. Educate patients: how to manage stress-dose steroids during illness, carry emergency injectables, and rebuild resilience step by step.

5. Look upstream: Address the chronic triggers—be it autoimmune disease, trauma, or environmental exposure—that first necessitated steroid use.

🧩 From Crisis to Clarity

Steroid-induced adrenal insufficiency isn’t just a side effect—it’s a teachable case of how chronic suppression without replenishment leads to collapse.

Through the lens of ERM and stress adaptation, it becomes clear:

“You’re not broken—you’re exhausted. You can recover.”

Understanding AI in this broader framework doesn’t just help patients survive adrenal crises. It helps them rebuild long-term resilience, from the inside out.

Vaidya, A., Findling, J., & Bancos, I. (2025). Adrenal insufficiency in adults: A review. JAMA. Advance online publication. https://doi.org/10.1001/jama.2025.5485

#Adrenal insufficiency, #Glucocorticoid-induced suppression, #Exposure-Related Malnutrition (ERM), #Stress adaptation, #Bioenergetic resilience