MON-485 Adrenal Insufficiency After Treatment With Budesonide: A Case Report and Literature Review

Abstract Disclosure: S. Chen: None. B. Sheridan: None. C. Deutsch: None. C. Vaz Wicks: None. Introduction: Side effects of long-term systemic corticosteroids are well known and have led to the use of alternative treatment regimens for inflammatory conditions. An attractive alternative is budesonide, a glucocorticoid characterized by high binding affinity to receptors as well as a high first-pass effect in the liver (90%), resulting in high anti-inflammatory activity while limiting its systemic corticosteroid effects. We present a rare case of adrenal insufficiency following treatment with budesonide for lymphocytic colitis. We also review the literature on the use of budesonide and its association with risk of adrenal insufficiency. Clinical case: An 81-year-old woman with post-surgical hypothyroidism presented with fatigue, thin hair, and brittle nails. The patient was on budesonide 9 mg daily for at least 6 months for lymphocytic colitis. Given symptoms and steroid use, she was evaluated for adrenal insufficiency. Laboratory assessment revealed low AM serum cortisol of 1.5 ug/dL (6.2-19.4 ug/dL) and low ACTH of 6.7 pg/mL (7.2-63.3 pg/mL). Repeat AM cortisol was low at 1.0 ug/dL (6.2-19.4 ug/dL) with low ACTH of 5.2 (6-50 pg/mL). Budesonide was tapered and the patient was treated with hydrocortisone 5 mg twice daily while awaiting HPA axis recovery. 6 months later, an ACTH stimulation test showed improvement in adrenal function with cortisol at 0, 30, and 60 minutes being 7.1, 12.4, and 14.7 ug/dL. Hydrocortisone was stopped and the patient continued to have normal morning cortisol and ACTH suggesting sustained HPA axis recovery. Discussion: Oral budesonide undergoes extensive first pass metabolism in the liver (85-95%), limiting systemic concentration and minimizing effect on the HPA axis. In particular, budesonide is favored in treating patients with IBD over prednisolone as studies have shown significantly less suppression of adrenal function with budesonide. Despite this, cases of AI have been reported from use of both chronic oral and inhaled budesonide. From published literature to date, AI has been reported after as little as 5 months of use and an average dose of 9 mg daily orally. The timeframe for adrenal recovery can be several months, as long as 6 months as seen in this case. Complications such as adrenal crisis can occur. This case highlights the potential of prolonged adrenal insufficiency from long-term use of oral budesonide. Clinicians should remain vigilant when prescribing budesonide and monitor for adrenal insufficiency. Presentation: Monday, July 14, 2025