ADRENAL PROBLEMS

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ADRENAL PROBLEMS

(Replacement Cortisone Therapy)

http://www.thyroiduk.org/

By Dr Barry Durrant-Peatfield MB, BS, LRCP, MRCS

 

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 " 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 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 underactive 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 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 in-patients.

 

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. A report 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 corti

sone 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, and 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.

 

The article on this page © 1994 Dr. Barry Durrant-Peatfield All rights

reserved.