MON-020 Recovery of HPA Axis With Tapering of Daily Methadone Dose: A Case Report

Abstract Disclosure: J. Delshad: None. S. Hossain: None. S.A. Marowa: None. D.S. Rosenthal: None. S.C. Kumar: None. H. Liao: None. Introduction: While Opioid-induced adrenal insufficiency (OIAI) is gaining recognition, it is still underdiagnosed, and much remains to be learned about recovery. Time to recovery and the allowable opioid dose in particular remain unclear. We present a case of a 37-year-old female on chronic high-dose methadone diagnosed with OIAI, who regained adrenal function by tapering the daily dose of methadone. Case: A 37-year-old female with a past medical history of polysubstance abuse was admitted to the hospital for dizziness on standing and hypotension. After careful history to exclude other causes, she was diagnosed with OIAI. She reported having been on chronic methadone for over ten years with a maximum dose of 150 mg daily. At the time of diagnosis, she was taking 80 mg methadone daily, and presented with exacerbated hypotension not responding to fluids. Serum cortisol measured at 10:30 AM was 1.89 ug/dL (5.27-22.45 ug/dL) and plasma ACTH was below 5 pg/ml (6-50 pg/ml). She was started on stress dose hydrocortisone which resolved her symptoms and stabilized her blood pressure. Her dose was tapered and ten days later, she was on a physiologic dose of 15 mg at 8 AM and 10 mg at 2 PM. Returning to the clinic three weeks after starting hydrocortisone, she reported that her methadone dose had been rapidly tapered to 60 mg daily. Her morning dose of steroids was held and a standard dose cosyntropin stimulation test was performed at this time with cortisol values <1.00, 2.93, and 2.13 ug/ml respectively at times 0, 30, and 60 minutes after administration of cosyntropin. Additionally, ACTH was <5 pg/ml, and DHEA sulfate was 10 mcg/dL (19-237) and she was switched to prednisone 5 mg daily for ease of administration. Three months after switching to prednisone, she returned to the clinic again reporting that her methadone had been further tapered to 40 mg daily. The morning dose of steroids was again held for a repeat cosyntropin stimulation test which revealed cortisol values of 5.29, 18.17, and 22.75 ug/ml respectively at times 0, 30, and 60 minutes. ACTH was 5 pg/ml and DHEA sulfate 86 mcg/dL and while lab values had improved, they were not sufficient to stop steroids. At her most recent clinic visit, nine months after the original diagnosis and still on 40 mg methadone daily, morning labs were drawn. Withholding prednisone, her HPA axis was considered to be recovered based on cortisol was 17.05 ug/ml and ACTH was 19 pg/ml. Blood pressure has remained stable and the patient was instructed only to take steroids during acute illness. Discussion: While OIAI is gaining recognition, we are still learning about the recovery of adrenal function in this population. Our case demonstrates recovery in a patient while still on 40 mg of methadone daily. Additionally, as DHEA sulfate recovered to normal limits before the cortisol levels, further studies should be performed regarding its prognostic value. Presentation: Monday, July 14, 2025