CORTISONE REPLACEMENT IN THE LOW ADRENAL RESERVE SYNDROME by Dr Barry J Durrant

Hypothyroidism

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.