Adrenal Problems: Replacement Cortisone Therapy
by Dr Thierry Hertoghe
The adrenals sit just above the kidneys and most of us have heard that these are responsible for the "fight or flight" reaction 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. We call this condition Low Adrenal Reserve, or simply, Adrenal Insufficiency.
The most severe form of the syndrome is called "Addison’s 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 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 and libido 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 over dosage 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 most satisfactory test for adrenal hormones is the adrenal stress index; a measure, four times in 24 hours, of Cortisone and DHEA. Measurement of urinary excretion may also be done.
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.
For mild to moderate adrenal insufficiency, the use of natural glandular concentrates has been found extremely helpful and benefit may occur within days. For more severe deficiency, the use of pregnelone, DHEA, 7-Keto DHEA and natural hydrocortisone may be considered.
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 dose it does not at all; and in any event, the adrenal activity is curtailed anyway, making the options quite clear. Suppression occurs in the super-pharmalogical 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 be a temporary increase of dose. Influenza, heavy colds, dental extraction, injury and the like, require, for example, the 5mgm 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 aging 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.