Adrenal Support – from The Great Thyroid Scandal
Copied from ‘The Great Thyroid Scandal and How To Survive It’ by Dr Barry Durrant-Peatfield MB BS LRCP MRCS Chapter 8 Hypothyroidism The Treatment
3. Provision of adrenal support.
I pointed out that anyone with thyroid deficiency over a period of time, especially if it is more than mild, is likely to have their deficiency accompanied by the Low Adrenal Reserve Syndrome. If this is not dealt with before providing supplementation, response may be disappointing, and there is a risk of a thyroid crisis. This occurs when the system becomes overwhelmed with thyroid replacement from the medication, which it is unable to deal with, and the patient may have violent palpitations, headaches or collapse. The obvious difficulty lies in knowing whether adrenal support is required. Well, the difficulty is more imaginary than real. Firstly, the history of the symptoms, the postural hypotension, the fainting attacks, the digestive upsets and other problems I mentioned in the last chapter, along with possible pointers from a blood test, are likely to make low adrenal reserve a strong possibility. Secondly, if there is any doubt, initial support must be given since there are real problems if it is needed and not given. Thirdly, prescribed in the way I am going to discuss in a few moments, there is no risk, since the amount of adrenal support is physiological (explained below). This means even if it isn’t necessary, no damage is done, no risks are taken, and it can be withdrawn whenever tough appropriate.
The guiding principle is to provide adrenal support physiologically. This means that the amount of supplementation is comparable to the amount actually produced by the body itself in the normal healthy state. The distinction between physiological dosage and therapeutic dosage is crucial to understand. A therapeutic dose is in excess of he natural production (or physiological) dose; and will inevitably suppress the natural production. This point is made clear in the use of hydrocortisone below.
To provide adrenal support, there are a number of options that may be used. The most obvious is to use the manufactured hydrocortisone provided as tablets as hydrocortisone B.P. (British Pharmacopoeia) 10 mg. The natural output of hydrocortisone is actually variable and may be as much as 200 mg. daily under stress and 40 6o mg. in a normal resting state. Obviously then, a dose significantly greater than 40 mg. daily will tend to take over the adrenal production of cortisone, and the adrenals could shut down completely. It must be said at once, so long as this suppression doesn’t last too long, the adrenals will pick themselves up again, and restart producing the necessary cortisone for themselves as before. One spectre that gibbers in the sight of many physicians is this adrenal suppression. It is only temporary unless very prolonged; and the adrenals will resume normal function as far as they are able when supplementation is discontinued. The problem is of course that they may not come back to normal until the thyroid/adrenal deficiency has been adequately treated for long enough. A physiological replacement level would therefore be 15 or 20 mg, daily, required until the patient is making a satisfactory response to the treatment as a whole.
I want to hammer home the distinction between physiological cortisone replacement, which may be quite essential to the overall management of thyroid/adrenal insufficiency, and therapeutic cortisone dosage. It was found as far back as 1948, that supra-normal dosage of cortisone had remarkable benefits on people crippled with rheumatoid arthritis and related collagen disorders systemic sclerosis, systemic erythematosis, and people invalided with intractable asthma, together with other, up to then, untreatable conditions. The downside to the miraculous recoveries cortisone brought to peoples’ lives, were side effects. They were the same as I mentioned with Cushing’s Syndrome; but in addition there was a risk of sudden death after operations or major trauma, with a generally reduced ability to deal with infection. This turned out to be due to adrenal suppression by the high doses of cortisone: when called to respond to a high challenge situation the adrenals were unable to do so; and the patient slipped into irreversible surgical shock and died.
When this became widely known cortisone was used with a great deal more care; doses were less and were given over a limited time interval, and when the cortisone was stopped it was done gradually so that the adrenals could pick up and revert to normal activity. As it does, the pendulum has now swung very far the other way; and in the minds of patients and doctors alike, there is a deep horror and aversion to the use of cortisone in any context whatsoever. This almost hysterical hostility to the use of cortisone, even its very mention, by physicians and their patients, is greatly to be deplored and is one important reason why the management of thyroid insufficiency is in such a parlous state and so misunderstood and misused. I must emphasise again, that the use of low dosage, that is physiological dosage, of cortisone is not only perfectly safe in restoring proper adrenal response, but is absolutely essential. Along with many of my American colleagues, I have seen the subject of much ill informed criticism of this view, based upon a prejudice arising from its previous history of improper use. But facts are facts and it is essential that physicians and patients alike rethink the whole problem. Two quotations from the great physician McCormack Jeffries are really quite relevant.
“Cortisol is a normal hormone, essential for life.”
“Most physicians today are under the impression that any dosage of cortisol can produce side effects that occur without any excessive doses.”
We must return to our theme. It is essential where low adrenal reserve is suspected, or indeed, obvious, that no thyroid supplementation should be considered until adrenal support is in place. Undoubtedly for the physician, the replacement of choice is hydrocortisone, since this though synthetically produced, is identical to naturally produced cortisone. But, the initial approach has to be restrained and cautious, and the lowest possible dose given at the start. I find that 1/4 of a 10 mg. hydrocortisone (that is 2.5 mg) is an excellent starting point. The reason hat it is so low to start with is that patients ill for some time, and perhaps receiving synthetic thyroxine, may have substantially high levels of T4 and T3 which the system cannot use. The adrenal support may kick in quite quickly, causing the T4 -> T3 conversion and receptor uptake to start working quite abruptly. This may cause a sudden overdose situation to occur. The patient may find the pulse rapidly accelerates to give palpitations in the chest or even promote irregularity of the heartbeat. They may feel ill, may collapse, they may have tremors in the limbs as if they were thyrotoxic. With small starter doses of adrenal support the risk of this is avoided. The first two or three days of 2.5 mg. of hydrocortisone given in the morning soon after waking, will be monitored by the patient for any adverse symptoms, checking pulse two or three times a day, and of the course morning basal temperature.
Normally there are no symptoms good or bad; but everyone is different and occasional marked sensitivity occurs. In such a case the hydrocortisone will be stopped for a day or so, and a much lower replacement level will be sought for. The most valuable alternative is the use of an adrenal glandular, such as “Adrenolyph” from Nutri Ltd, or in the USA, Isocort, which being natural adrenal extracts, require no prescription. The amount of cortisone is extremely low, only in trace amounts, but will be sufficient to start the adrenal support going. I shall have more to say about this treatment later on.
Once the hydrocortisone is started the full support dose is now built up to effective levels over 2 or 3 weeks. The 1/4 tablet a day is increased to 1/4 tablet twice a day; then after a few days, three times a day and up to a 1/4 four times a day spread out throughout the waking day. The reason for this is that it is not store by the body and gets rapidly used; 2 or 3 hours will see it pretty well used up completely. Since a smooth level of support is desirable, the dose does need to be spread out. The final dose is usually 20 mg. daily, that is 1/2 tablet four times a day; but careful adjustments relating to the response, may take the dose to 25 or 30 mg. daily, exceptionally even 40 mg. These higher doses are related more to absorption in the stomach, not to deficiency, but low adrenal reserve reaching Addisonian levels may make such doses necessary.
On this regime, the patient may feel considerable improvement after even a few days as thyroid processing of existing thyroid in the bloodstream improves. It sometimes happens that the improvement is so marked, and the hypothyroid symptoms are so much relieved, that supplementary thyroid may only need to be in very small amounts, or even not required at all.
The usual pattern of events, however, is to start thyroid supplementation as soon as the adrenal support has been established. How this may be done, we shall come to shortly. The disadvantage of hydrocortisone is that it needs to be given 4 times a day to be fully effective. Some patients do as well, or better, on he widely used synthetic derivative, prednisolone. The equivalent dose of 20 mg. of hydrocortisone id 5 mg. of prednisolone, which may be increased up to 7.5 mg. and sometimes more. This needs to be given only once a day, most commonly in the morning, since it remains active in the system for about 24 hours. Because prednisolone can irritate the stomach on occasion, it is usually given in an enteric coated version called Deltacortril; and if given with food the risk of gastric irritation is further minimised.
It is sometimes useful to prescribe instead, a mineralocorticoid., and the most useful is fludrocortisone, or Florinef, in doses of 0.1 mg. once or twice a day. This may further improve the adrenal response when given together with the glucocorticoids, hydrocortisone and prednisolone. There are other synthetic cortisones available, but in general they shouldn’t prove necessary.
The length of time necessary to provide adrenal support is really infinitely variable. My normal practice has usually been to obtain the best result with thyroid and adrenal support, and after six or eight weeks, start to tail off the cortisone supplement. If there is no adverse result it may then be stopped taking, say, four weeks in the process. Sometimes the patient starts to lose ground; and it must then be restarted, and in another eight weeks or so another attempt to tail off is made. Sometimes, the adrenals have been so badly hit that the adrenal support may be required for months; and if the adrenals never fully recover, for a more indefinite time. Again I emphasis, that if adrenal support is required, it must be given for as long as it takes; there is no risk to this since one is simply restoring the situation to normal, in the same way, and for the same reason, that thyroid support may have to be given indefinitely.
To summarise the indications for adrenal support we may say:
1 Where an abnormally high or abnormally low DHEA, and/or abnormally low cortisole blood test shows weak adrenal function.
2. Many symptoms, and clinical signs, notably postural hypotension, suggest weak adrenal response.
3. The thyroid deficiency state has been present some considerable time and getting worse.
4. Previous treatment with thyroxine has been unsuccessful or even worsened the situation.
5. There has been thyroid surgery or radioactive iodine ablation.
6. Thyroid blood tests are normal but the patient is clinically hypothyroid.
7. Previous major surgery.
We must now turn our attention to the thyroid deficiency state. Having put in place the adrenal support, it is now safe to provide the thyroid support; and we can be sure that it is actually going to work. Although there are several options available, you are most likely to be offered only one if you can convince the doctor in charge of your need. If you can’t, all is not lost. I have a chapter later explaining how you can help yourself.
Provision of Adrenal Support, In Chapter 8: Hypothyroidism The Treatment.
The Great Thyroid Scandal and How to Survive It,
by Dr Barry Durrant-Peatfield MB BS LRCP MRCS, pp 106-113