Steroid Withdrawal Syndrome 

Acupuncture for steroid withdrawal is a form of treatment that involves inserting very thin needles through a person's skin at specific points on the body, to various depths. Research suggests that it can help relieve pain, and it is used for a wide range of other complaints.

Steroid withdrawal syndrome is defined by symptoms of glucocorticoid deficiency such as general malaise, lethargy, postural dizziness, generalized weakness, arthralgia, headaches, mood swings, and emotional lability, in the setting of a proven normal HPA axis [10]. The integrity of the HPA axis can be assessed by measuring the 9 AM serum cortisol level [10]. A value <100 nmol/L is suggestive of cortisol insufficiency whereas a value >450 nmol/L is consistent with cortisol sufficiency [10]. A suboptimal value of 9 AM serum cortisol level is defined as a value between 100 to 450 nmol/L, and usually, a patient with steroid withdrawal syndrome has a suboptimal value of 9 AM serum cortisol [4]. For further confirmation of adrenal insufficiency, stimulation tests such as the short synacthen test, glucagon stimulation test, or insulin tolerance test can be performed [10]. In this patient, however, we did not proceed with the stimulation test since her history was very suggestive and due to the lack of resources. Furthermore, the patient’s symptoms improved after steroid replacement.

The use of traditional complementary medicine (TCM) is common in Malaysia for Holistic Care, particularly in a community setting. More than half of the patients have used at least one type of traditional medicine, and the most frequently used is herbal medicine. Studies have shown that steroids are contained in more than half of the traditional medicine products that have been tested, and most of them were not registered. Traditional medications that are contaminated with steroids can cause conditions, such as steroid withdrawal syndrome, especially if taken for a long period. Steroid withdrawal syndrome occurs when there is an abrupt cessation or reduction of steroids in patients who take a supraphysiologic dose of steroids over a long time. The symptoms are like adrenal insufficiency, but the patient’s serum cortisol level is suboptimal. Although the symptoms are self-limiting, doctors need to be aware of this condition as steroid replacement may alleviate the symptoms and improve the patient’s quality of life.

Morning serum cortisol was measured to rule out steroid withdrawal syndrome based on the patient’s history and physical findings. Serum cortisol was within the normal range at 193.1 nmol/L (normal range, 166–507 nmol/L). The patient was then treated for steroid withdrawal syndrome. Mild transaminitis could have been caused by hepatotoxicity induced by TCM use.

Majun is one of the most common herbal medicines used by the Malay population. Usually, it is produced from various tree roots or herbs and is processed into pills or paste. Furthermore, sometimes these traditional medicines are mixed with toxic heavy metals or undeclared drugs [5]. In 2005, half of the traditional medicine products that had been tested contained steroids, and most of them were not registered [3]. However, in our case, the patient refused to give a sample of her herbal preparation; therefore, we were unable to confirm the presence of steroids in her herbal medication.