{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T15:07:03Z","timestamp":1789657623460,"version":"4.0.1"},"reference-count":33,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p>Adrenal suppression is a potentially life-threatening consequence of chronic glucocorticoid (GC) therapy in Duchenne muscular dystrophy (DMD), placing individuals at risk for adrenal insufficiency and adrenal crisis during increased physiological stress, missed GC doses, abrupt discontinuation, or transitions between GC regimens. Management is increasingly complex because DMD treatment now includes multiple GC agents, including prednisone\/prednisolone, deflazacort, and vamorolone, as well as daily, intermittent, and transition regimens that differ across countries and clinical settings. Although general principles of adrenal insufficiency prevention are well established, implementation remains challenging because of global variability in drug availability, institutional stress-steroid protocols, clinician experience, and caregiver education. This article discusses key sources of variability in adrenal suppression management for individuals with DMD and presents the 2025 PJ Nicholoff Steroid Protocol as an example of a practical, DMD-specific framework. The updated protocol incorporates newer therapies such as vamorolone and emphasizes anticipatory education, written stress-steroid plans (including a weight-based approach), safe GC tapering, confirmation of hypothalamic\u2013pituitary\u2013adrenal axis recovery, and careful management of transitions between GC agents and regimens. This structured approach aims to support safer and more consistent adrenal suppression management for individuals with DMD receiving chronic GC therapy through six critical concepts.<\/jats:p>","DOI":"10.3389\/fneur.2026.1926817","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T14:42:30Z","timestamp":1789656150000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["A structured approach to address variability in the global management of adrenal insufficiency in Duchenne muscular dystrophy: the 2025 PJ Nicholoff steroid protocol"],"prefix":"10.3389","volume":"17","author":[{"given":"Anne Marie","family":"Sbrocchi","sequence":"first","affiliation":[{"name":"Division of Pediatrics and Metabolism, Montreal Children\u2019s Hospital, McGill University Health Center","place":["Montreal, QC, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra","family":"Ahmet","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, Department of Pediatrics, Children\u2019s Hospital of Eastern Ontario, University of Ottawa","place":["Ottawa, ON, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathi","family":"Kinnett","sequence":"additional","affiliation":[{"name":"Parent Project Muscular Dystrophy (PPMD)","place":["Washington, DC, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria-Elena","family":"Lautatzis","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, Children's Hospital of Manitoba, University of Manitoba","place":["Winnipeg, MB, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugh J.","family":"McMillan","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, 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Ontario, University of Ottawa","place":["Ottawa, ON, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sasigarn A.","family":"Bowden","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Nationwide Children\u2019s Hospital, Ohio State University","place":["Columbus, OH, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne M.","family":"Connolly","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Nationwide Children\u2019s Hospital, Ohio State University","place":["Columbus, OH, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Garey","family":"Noritz","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Nationwide Children\u2019s Hospital, Ohio State University","place":["Columbus, OH, United 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