CORTISONE REPLACEMENT IN THE LOW ADRENAL RESERVE SYNDROME
by Dr Barry J Durrant-Peatfield
M.B., B.S., L.R.C.P., M.R.C.S.
THE CLINIC
86 Foxley Lane Purley
SURREY CR2 3EE
Telephone - 020 8660 0905
Cortisone therapy was first brought to the world of medicine in the thirties, by the work of Hench & Kendal. By the late forties, and early fifties, cortisone was hailed as a medical breakthrough in the treatment of rheumatoid arthritis,and similar illnesses, asthma, and as a lifesaver in the management of surgical shock. Yet, within a few years, doctors and patients alike, became fearful of its use; an anxiety which persists very much today, thus denying many people enormous benefits.
The problem lay in dosage. Really quite large doses were given - and sometimes are today - which caused various side effects. The swelling and puffiness of the face; weight gain, osteoporosis, peptic ulceration, bruising, fluid retention are generally quite well known. Yet these occur only in doses way above the natural levels of cortisone in the body; what we may call "pharmacological" doses. This collection of symptoms - or syndrome - occurs in nature when the adrenals become seriously overactive; this is called Cushings Syndrome.
What was not realised until quite a lot later, and regrettably in some quarters still today, is that cortisone in small amounts, used as replacement therapy, for deficiency, can be of extraordinary benefit, and cause no side effects of any kind. This is the use of cortisone replacement therapy in physiological doses, when the side effect problem no longer applies. The use of a cortisone derivative in your treatment is in this way; to correct a deficiency, brought about by low adrenal function.
The adrenals sit just above the kidneys in the loin, one on each side. Their tasks are many and varied; and are so important, that if you lose your adrenals, you die within three days. The inside of each adrenal produces adrenalin, which is the hormone that gives us a sudden burst of energy or strength when confronted with a crisis situation - the "fight or flight" scenario. It is the rim, or cortex, of each adrenal, that most concerns us for the present. It produces a number of complex hormones with vital roles to play, and are essential in the system's response to prolonged stress; e.g. infection, injury, starvation, massive exertion. The first group is the glucocorticoids (mostly hydrocortisone), whose job is mostly to stimulate conversion of protein to glucose; and maintain the tone of the vascular (or blood vessels) system.
The second group comprises the mineral corticoids, which regulate the proper balance in the body of sodium and potassium, and are therefore to do with fluid retention and blood pressure. Aldosterone is the chief. The third type are the androgens, (male sex hormones), and are represented by Dehydroepiandrosterone, (DHEA for short), and androstendione. These have as their main job, the promotion of repair and growth in the tissues.
Fourthly, are the oestrogen's, that back up the oestrogen made by the ovaries - as, for example, in the menopause. Other hormones are suspected, but not yet isolated. The output of these hormones is cyclical, with maximum level early in the morning, and least at night.
Our deepest concern here, is the crucial importance of the adrenal cortex hormones in the system's response to stress. Briefly, there is a rapid increase of the glucocorticoids, to enable the body to cope. It is the failure of this mechanism to work properly, in the presence of general stress, or the stress of illness, that we are concerned with in the use of replacement cortisone therapy.
This condition we call Low Adrenal Reserve, or simply, Adrenal Insufficiency. The most severe form of the syndrome is called "Addisons Disease", after the great Guys Physician, Thomas Addison, who was the first to describe it in 1855.
It was then usually due to tuberculosis destroying the glands. Patients were dusky coloured, with terrible weakness, malnutrition, collapse and coldness, and the illness ran a fatal course. It is pretty rarely seen in clinical practice. But we are concerned with the mild form of deficiency, where the patient may be well, until subjected to stress and/or illness. Then, many of the symptoms may appear with prostration and collapse; or there may be a level of insufficiency present all the time, with varying degrees of weakness, muscle and joint pains, and general ill health.
So what do we look for in the way of symptoms? It is rarely clear cut, because the deficiency is so often part of another illness, and may therefore have something of the symptoms of both. We are particularly concerned with thyroid deficiency, which, if of longstanding, or fairly severe in degree, is most often associated with adrenal insufficiency, as well as a direct result of the stress on the system low thyroid function will cause.
The patient will complain of weakness and episodes of prostration, frequently feeling quite unwell without being able to pinpoint the cause. Episodes of dizziness, sometimes cold sweats, caused by the blood sugar becoming abnormally low, are not uncommon. Often, an odd internal shivering is described. Aches and pains of a rheumatic nature are other frequent complaints. The patient often complains of the cold, and is likely to be cold to the touch. The subject does not feel well, and may look ill, with dark rings under the eyes, and a general pallor. There are likely to be digestive problems, with excessive wind and bloating, and bowel disturbances. The menstrual cycle may be disturbed, or absent; libidos low. Depression and anxiety may also be a feature.
Some of the symptoms complained of by patients with M.E. - Myalgic Encephalitis - are very similar, leading to the well grounded suspicion that M.E. is associated with low adrenal reserve. Certainly, frequent minor illnesses are common, with an overlong course of quite minor infections, which may also have an unusually severe effect on the patient.
Low thyroid function has some of these features, and it may be difficult to distinguish one from the other; In fact it should not be necessary because, as I pointed out above, as the two are often together, so too must the treatment overlap and be designed to relieve both.
The complications of treating hypothyroid or under active thyroid patients) is that their consequent poor adrenal reserve may become suddenly obvious, as soon as the thyroid is treated. The thyroid supplementation may, at worst, precipitate the adrenal problem; but what usually happens, is that the thyroid replacement may either not apparently work at all, or the patient may have thyroid overdosage symptoms on quite a low level of replacement. Hence, where low adrenal reserve is suspected, it is possibly dangerous, and certainly ill advised, to treat the patient without supplementation of the adrenals, in the manner explained further below.
If a high index of suspicion of adrenal insufficiency is raised by the history given by the patient, then what are the signs the doctor looks for to establish the diagnosis?
Actually, it is sometimes difficult where the problem is not particularly severe; but there are some pointers. The blood pressure is usually quite low, often very strikingly so. The difference between the lying, (or sitting) blood pressure, and the standing one, may be very important. Normally, it rises when the patient stands. In low adrenal reserve, it either does not change at all, or lowers further. The pupil reflex is slow, or unstable, or even reversed, to bright light. Reflexes may be abnormal, especially the Achilles reflex - in the heel. The heart sound is characteristically altered.
It is satisfactory to confirm the clinical impression by blood tests; but these sometimes are unhelpful. The level of cortisone in the blood may be measured, but it is widely variable. However, DHEA, mentioned above, is quite a good indicator of adrenal cortex function. The urinary excretion of adrenal hormones is an excellent indicator - but the practical problems, (it has to be over 24 hours), and the expense of really good laboratory analysis, tend to limit this test to hospital inpatients. It is, in our view, perfectly practical and reasonable, to establish the diagnosis on clinical grounds, and because the therapy given is of very low - physiological - doses, there is no possible risk to the patient, however long it is needed. In a very large number of cases, the adrenal insufficiency may right itself over two or three months, making further supplementation unnecessary.
The Treatment
You will be given hydrocortisone 10mgm, which is the natural form, to take in a dose appropriate to your needs. Half a tablet three or four times a day is usual, later to be increased, if required. Hydrocortisone has the problem of very rapid uptake by the system, and it needs to be given every four hours, at least. This creates practical problems for many patients, and we use more often, Deltacortril, or Prednisolone. 2.5mgm is usually given to start with, increasing to 5mgm after a few days. Rarely, a total dose of 7.5mgm may be required.
Most patients feel benefit within a few days. You will be asked to ring the surgery if you are in the slightest doubt about how you feel, or how things are going. Are port by phone after a week is pretty important, and then we see you in two or three further weeks to assess matters. You will probably have been asked to keep a diary of events. If you have a thyroid problem, the thyroid replacement will start after a week, at a very low dose, working slowly upwards.
It sometimes takes many weeks for all the benefits to come through, but some improvement is clear within a week or so. Adrenal insufficiency related to low thyroid function corrects itself, as the thyroid levels improve, and usually after, two, three or four months, have recovered sufficiently for the cortisone therapy to be stopped.
The question is often asked. Will the cortisone replacement suppress my adrenals? The answer is that in physiological doses it does not at all; and in any event, the adrenal activity is curtailed anyway, making the options quite clear. Suppression occurs in the superpharmalogical doses, which do not concern us in this context. Even then, the adrenals are able to recover if the primary illness is dealt with, and the dose reduced gradually.
Low adrenal reserve means that under a state of challenge, the problem is going to show. While on replacement treatment therefore, any further illness and stress is best dealt with by a temporary increase of dose. Influenza, heavy colds, dental extraction, injury and the like, require, for example, the 5 mgm Deltacortril to be doubled, just for a few days. (I find that a 5mgm dose almost completely prevents jet lag; and influenza is over in one or two days.)
We have now a considerable fund of practical experience in the treatment of the adrenal deficiency syndrome, and are very much aware of its great benefit. It should not be considered in isolation, however, any may well be part of the management of other deficiencies. The ageing process is the result of deficiency in a number of different aspects of the system; so that full benefit may not be gained until both nutritional and hormonal imbalances are looked for and corrected.
During the time we are assessing your medical problem, we will include all that I have been talking about, as well as those aspects related to the menopausal situation, both for men and women.
