Treating Adrenal insufficiency:Cortef is best approach

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Note his statement: "Cortef is much more effective than prednisone in CFIDS/FMS."Highly Effective Treatment of Fibromyalgia and Chronic Fatigue Syndrome: Results of a Placebo Controlled Study and How to Apply the Protocol

by Teitelbaum, MDhttp://www.townsendletter.com/Oct_2002/fibromyalgia1002.htmAdrenal Insufficiency

The hypothalamic-pituitary-adrenal (HPA) axis does not function well in CFIDS/FMS.8 Dr. Jefferies, a professor of medicine at the University of Virginia Medical School and previously a professor at Case Western University School of Medicine, is the world's leading clinical expert on subclinical adrenal insufficiency. His book Safe Uses of Cortisol discusses the history of this disease and its treatment.9 Because early researchers used massive doses of cortisol (not knowing the physiologic dose), their patients developed severe complications. What is not common knowledge is that these side effects are not seen with physiologic dosing of Cortef (that is, up to 20 milligrams [mg] a day).10 Twenty mg of hydrocortisone (Cortef) is equal to 4 to 5 mg of prednisone.

To put it in perspective, if the early thyroid researchers had given ten times the physiologic dose of thyroid hormone (for example, 1,000 to 2,000 mcg qd instead of 100 to 200 mcg), a situation analogous to early adrenal research, many people would have had severe complications. Thyroid hormone would be viewed as very dangerous and we would only be treating hypothyroid patients on the verge of myxedema coma. In adrenal insufficiency, this is what occurs now. Many hypoadrenal patients are only treated when they are ready to go into ian crisis. Research and clinical experience shows that this approach misses most hypoadrenal patients.11

Symptoms of an underactive adrenal include weakness, hypotension, dizziness, sugar craving, and recurrent infections – all of which are common in CFIDS/FMS. I evaluate CFIDS/FMS patients' adrenal function with a morning cortisol level and, when available, a cortrosyn stimulation test. The test must begin between 7:00 and 9:00 a.m. The patient should not eat anything the morning of the test and also have no caffeine for twenty-four hours before the test. Check a baseline cortisol level and, if convenient, then do the cortrosyn stimulation test by giving ACTH (Cortrosyn) 25 units or 1 unit IM (current data suggests the 1 unit Cortrosyn test is more reliable) and recheck cortisol levels at one-half hour and at one hour. Although a baseline of 6 mcg/dl is often considered "normal," most healthy people run approximately 16 to 24 mcg/dl at 8:00 a.m.

My treatment guidelines are that if the baseline cortisol is less than 16 mcg/dl or the cortisol level does not increase by at least 7 mcg/dl at thirty minutes and 11 mcg/dl at one hour, or does not double by one hour and is less than 35 mcg/dl, I treat for adrenal inadequacy. Natural treatments include:

1. Adrenal Glandulars.

2. Panax ginseng 100-500 mg 2 x day

3. Sustained release pantothenic acid (Vitamin B5) 1000 mg 2 x day

4. Vit C 500-2000 mg/day

5. Licorice(not DGL)

If these do not take care of the problem, consider a therapeutic trial of 5 to 15 mg Cortef in the morning, 2.5 to 10 mg at lunch time and 0 to 2.5 mg at 4:00 p.m. (maximum of 20 mg a day). Most patients find 5 to 7 1/2 mg qAM plus 2 1/2 to 5 mg at noon to be optimal (the equivalent of 1 1/2 to 3 mg prednisone daily). Cortef is much more effective than prednisone in CFIDS/FMS.

After nine to eighteen months, taper the treatments off over a period of one to four months. If the other physiologic stresses, such as infections or fibromyalgia, have been eliminated, the patient's adrenal function may be adequate or normalized. If symptoms recur after the treatments, continue treatment with the lowest optimal dose.

Improvement is often dramatic and is usually seen within two to four weeks. If using glandulars or Cortef, the dose should be doubled during periods of acute stress and raised even higher during periods of severe stress such as surgery. Consider also giving the patient 1,000 mg of calcium and 400 international units (IU) of vitamin D daily with Cortef.

There are different approaches to treatment and more is not better. High dose Cortisol taken at night will worsen already disrupted sleep patterns. A recent study by Strauss published in the Journal of the American Medical Association gave too high a dose (about 25 to 35 mg a day) and too much at night – severely disrupting patients' sleep (p<.02). Although he did not treat the sleep disorder, most patients felt somewhat better on treatment. A small percentage of the patients had significantly decreased post treatment Cortrosyn tests, without complications, and he, I believe incorrectly, recommends against using Cortef in CFIDS/FMS.12 Our study did not show adrenal suppression using lower Cortef dosing.13 Dr. Jefferies, with thousands of patient-years' experience in using low-dose Cortef, recommends an empiric trial of Cortef in all patients with severe, unexplained fatigue.14 Our research and clinical experience suggests this is the best approach.