How To Start Using Cortisone by Dr Barry Durrant-Peatfield
As you are aware, there is an inside and an outside to your adrenals, each responsible for different things.
The ‘inside’ produces adrenalin and we all know this allows the body to deal with immediate stress and about the ‘flight or flight reaction. When you have a surge of anger or fear, these hormones are released into the blood stream, where they mobilise extra blood sugar which increases your BP and heart rate. With an adrenalin surge, you have an immediate increase in energy and muscle strength and you can suddenly cope with huge energy demands and deal with a huge crisis situation.
The ‘outside’ though is what concerns most of us and this has 3 layers.
The outer layer produces mineralocorticoids, represented chiefly by aldosterone which regulates fluid and electrolyte balance by promoting the retention in the blood stream of sodium and the loss of potassium.
The next layer produces the glucocorticoids, mostly cortisol (hydrocortisone, but also cortisone. The active hormone is hydrocortisone. The glucocorticoids have two main effects: one is the ability to mobilise and form glucose from non-sugar sources (fats and proteins); the other is to maintain blood pressure. In this way, the glucocorticoids work in the body to protect the body from longer term (moderate and chronic) stress.
The last layer produces sex hormones and anabolic steroids, that is, androgens and oestrogen. These are represented by DHEA and androstendione. The latter can be converted in the fatty tissues of the body to the female sex hormone oestriol. Testosterone is also produced.
Normally, these hormones are produced elsewhere, but if normal sources fail, the adrenals can take over. Androgens have the important role in promotion growth and repair of body tissue, especially muscle tissue, as well as their obvious purpose keeping men male. This layer is weakened by the passage of time and its hormones decline until they are running at a fraction of the output they were in youth.
It is the cortisone production by the adrenals that concerns us. Our ability to produce this hormone depends on our capacity for fighting off the effects environmental challenges. Injury, illness, deprivation, work or personal stress. Cortisone is the stress buster of the body. It is produced regularly in peaks and troughs. The highest levels are in the morning, declining as the day progresses and building up again during the small hours. Although the word cortisone may worry you, it is a natural substance that we all make and need for our health. In normal health, we make it all our lives, with fairly minimal falling off with age. Problems arise, however, if the adrenals go wrong. This may happen in two ways.
The first is over production of cortisone. This may be a physiological response to high levels of stress (of any kind). This could lead to Cushing’s syndrome. The second is the opposite end of the scale which is more common, but which, in its milder form, may escape detection. The more ‘severe’ form results in Edisons disease. The adrenals are more likely however, to be damaged by other processes, most commonly autoimmune diseases. There is a steady loss of function, with accumulating symptoms of an illness. While gross adrenal failure is not too difficult to diagnose, if it is thought about, it is partial adrenal failure we are concerned about here.
Low adrenal reserve is characterised by firstly, a poor response to stress of any kind. Patients report that they feel ill when stressed and have to back off at the smallest degree of stress. Illness like flu or a cold has an out of proportion devastating effect, lasting longer than it should, and causing much more severe symptoms than would be expected. Patients a chronically hypoglycaemic, and have episodes of faintness and general un-wellness relieved only by sweet tea, or chocolate or a piece of cake. ) People often confuse hypoglyceamia, which is episodic low blood sugar, with diabetes. Diabetes is of course quite the reverse? The system loses its ability to control blood sugar, which may rise to abnormally high levels as the result of failure to make enough insulin, or respond to the insulin properly.
Damaged or overworked adrenals will work less well than normally and a lowered production of hydrocortisone and cortisol from unresponsive adrenals will affect thyroid production, conversion and receptor uptake. For people who are scared of using hypdrocortisone, I should mention that the scary bit is for those people who take massive doses of the stuff. If your adrenals are not putting out the correct amount of adrenal hormones, then, like your thyroid, you simply replace that amount. If you are hypothyroid, your body cannot function without replacing the thyroid hormones you are not secreting, and it is the same with your adrenals. You start cortisone with a low dose like thyroid hormones and increase slowly until you find the dose that makes you well.
To jump on if thyroid hormone is not being produced as it should, nothing will work properly and that also means the adrenals. This situation is compounded by the fact that low thyroid output is a stress situation. To enable the system to cope with low thyroid output, the adrenals are obliged to produce an increased level of hydrocortisone. This may work well, for a considerable period of time, if the thyroid deficiency isn’t too bad. But it slowly worsens and the adrenals are called to further compensate for the stress this produces. Eventually of course, the adrenals begin to cope less well and the continued strain causes adrenal exhaustion. The syndrome of low adrenal reserve is now present.
Supplementary thyroid hormone may of itself cause a stress situation if the system cannot cope with it. It is possible to trigger off a thyroid/adrenal crisis and collapse using the wrong sort of dose, and ignoring the necessity of the provision of adrenal support, i.e. ensuring the adrenals CAN cope with the strain. Indeed it is possible by using thyroxine, when the patient cannot convert properly, to cause a full Addisonian crisis, which may be fatal.
As you are aware, the inactive hormone T4 has to convert to the active hormone T3. If you have low adrenal reserve, the reaction doesn’t proceed as it should, and the body may become toxic with unused and unstable T4. The problem doesn’t end there; the T3 has to be taken up by the receptors within the cell wall, to be passed into the cell. This uptake is degraded by adrenal insufficiency and the receptors become dormant or may disappear or may become resistant. In this situation, even if T3 is available, the system can become toxic if it cannot be used properly. You can see how desperately important the adrenals are, and equally, how important it is to provide adrenal support, in the form of cortisone supplementation when low adrenal reserve e is present.
I must tell you now that the failure of thyroid supplementation to restore normal health may well be largely down to the adrenal problem. This is scarcely ever considered by physicians since they do not recognise low adrenal reserve, and may even miss the diagnosis of fully established Addison’s disease.
Thousands of people with hypothyroidism are never quite well since using the blood tests as a guide only, the endocrinologists, with few exceptions, oblige their patients to lurch from one dose to another. The patients may have windows of feeling better, but may feel either under-active, or toxic for much of the time. The wicked thing is that when they tell their doctor “Look, I really don’t feel right”, they will be told, since the blood tests show that they are at the correct levels, they MUST be right and perfectly well whatever they may say. The patient is then probably offered Prozac or other antidepressant, or counselling, or become labelled a “heartms8hi~” patient and you can see now why the blood tests may be completely misleading. If the thyroid supplementation isn’t being used properly and is not being processed into the tissues, it WILL cause the blood levels to be normal, or even raised. In this situation, which is likely to affect all hypothyroid sufferers sooner or later, if this is not taken account of, the patient will NEVER be well.
Whatever you may be told, adrenal insufficiency in thyroid disorders is very common indeed and should always be considered at the onset of treatment. Failure to respond to thyroid supplementation, or actually feeling less well, is likely more often than not to involve the low adrenal reserve syndrome.
We all know about the scary high doses of cortisol that have been used on patients in the past and there is a chapter about this in his book. However, 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 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 often absolutely essential. Along with other doctors, I have been the subject of much ill informed criticism of this view, based on 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 quotes from the great physician McCormack Jeffries are 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 with any excessive doses”
The initial approach has to be restrained and cautious, and the lowest possible dose given at the start. I find that quarter of a 10 mgs hydrocortisone (that is 2.5mgs) is an excellent starting point. The reason that it is so low to start with is the fact that patients, ill for some time, and perhaps receiving synthetic thyroxine, may have substantially high levels of T4 and T3 which they system cannot use. The adrenal support may kick in quickly, causing the T4 conversion to T3 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 2.5mgs 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 course, the 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 e is the use of an adrenal glandular, such as “Adrenolyph” from Nutri Ltd, which being a natural adrenal extract requires no prescription. The amount of cortisone is extremely only, only in trace amounts, but will be sufficient to start the adrenal support going.
Once the hydrocorisone is started the full support dose is now built up to effective levels over 2 or 3 weeks. The 2.5mg tablet a day is increased to 2.5mg tablet twice a day. After a few days, three times a day and up to a 2.5mgs four times a day spread out throughout the waking day. The reason for this is that it is not stored by the body and gets rapidly used. Two or three 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 mgs daily, i.e. 10.0 mgs first thing in the morning, 5 mgs mid day and 2.5 mgs at tea time and 2.5 before bed time, but careful adjustments relating to the response, may take the dose to 25mgs or 30 mgs daily, exceptionally even 40mgs. These higher doses are related more to absorption in the stomach than to deficiency, but low adrenal reserve reaching Addisonian levels may make such doses necessary.
On this regime, the patient may feel a 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. The disadvantage of hydrocortisone is the fact that it needs to be given four times a day to be fully effective e. Some patients do as well, or better, on the widely used synthetic derivative prednisolone. The equivalent dose of 20 mgs of hydrocortisone is 5 mgs prednisolone, which may be increased up to 7.5mgs and sometimes more. This needs to b e 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, the most useful is fludrocortisone or Florinef, in doses of 0.1mg 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. Dr Peatfield says his normal practice has usually been to obtain the best results 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. I emphasise, 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:
Where an abnormally high or abnormally low DHEA, and/or abnormally low cortisol blood test shows weak adrenal function.
Many symptoms, and clinical signs, notably postural hypotension, suggest weak adrenal response.
The thyroid deficiency state has been present some considerable time and getting worse.
Previous treatment with thyroxine has been unsuccessful or even worsened the situation.
There has been thyroid surgery or radioactive iodine ablation.
Thyroid blood tests are normal but the patient is clinical hypothyroid.
Previous major surgery.