Adrenal Fatigue & Glucocorticoid Use

[Michael Scally MD]

I have read within this forum and others the use of glucocorticoids for "adrenal fatigue." I have read many doses ranging up to 100 mg/day in divided doses. I am interested to know if you have taken, are taking, or know of forums/links of the doses of glucocorticoids in "adrenal fatigue." This will part of a thread on the benefits/risks of such a treatment. Also, cites to studies describing their use are helpful and appreciated. [Yes, I have a library of research on this topic. I am waiting to hear from the reader.]

 

[hardasnails1973]

I have read within this forum and others the use of glucocorticoids for "adrenal fatigue." I have read many doses ranging up to 100 mg/day in divided doses. I am interested to know if you have taken, are taking, or know of forums/links of the doses of glucocorticoids in "adrenal fatigue." This will part of a thread on the benefits/risks of such a treatment. also, cites to studies describing their use are helpful and appreciated. [Yes, I have a library of research on this topic. I am waiting to hear from the reader.]

Amazon.com: Jeffrey Dach MD's review of Safe Uses of Cortisol

These are the guidelines we follow
100 mgs of HC is not being used to treat adrenal insufficency properly.

 

[chemman]

BINGO. This is much-needed thread.

 

[Michael Scally MD]

BINGO. This is much-needed thread.

Thanks for the study, but it deals with adrenal insufficiency, not "adrenal fatigue." It will be important, though, in the discussion as to where and what people consider the difference between the two. To that end, please post on this area also.


Mah PM, Jenkins RC, Rostami-Hodjegan A, et al. Weight-related dosing, timing and monitoring hydrocortisone replacement therapy in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2004;61(3):367-75.

OBJECTIVE: The objective of this study was to examine the variables determining hydrocortisone (HC) disposition in patients with adrenal insufficiency and to develop practical protocols for individualized prescribing and monitoring of HC treatment.

DESIGN AND PATIENTS: Serum cortisol profiles were measured in 20 cortisol-insufficient patients (09.00 h cortisol < 50 nmol/l) given oral HC as either a fixed or 'body surface area-adjusted' dose in the fasted or fed state. Endogenous cortisol levels were measured in healthy subjects. Pharmacokinetic analysis was performed using P-Pharm software, and computer simulations were used to assess the likely population distribution of the data.

RESULTS: Body weight was the most important predictor of HC clearance. A fixed 10-mg HC dose overexposed patients to cortisol by 6.3%, whereas weight-adjusted dosing decreased interpatient variability in maximum cortisol concentration from 31 to 7%, decreased area under the curve (AUC) from 50 to 22% (P < 0.05), and reduced overexposure to < 5%. Food taken before HC delayed its absorption. Serum cortisol measured 4 h after HC predicted cortisol AUC (r(2) = 0.78; P < 0.001).

CONCLUSIONS: We recommend weight-adjusted HC dosing, thrice daily before food, monitored with a single serum cortisol measurement using a nomogram. This regimen was prospectively examined in 40 cortisol-insufficient patients, 85% of whom opted to remain on the new thrice-daily treatment regimen.

 

[chemman]

Thanks for the study, but it deals with adrenal insufficiency, not "adrenal fatigue." It will be important, though, in the discussion as to where and what people consider the difference between the two. To that end, please post on this area also.


Mah PM, Jenkins RC, Rostami-Hodjegan A, et al. Weight-related dosing, timing and monitoring hydrocortisone replacement therapy in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2004;61(3):367-75.

OBJECTIVE: The objective of this study was to examine the variables determining hydrocortisone (HC) disposition in patients with adrenal insufficiency and to develop practical protocols for individualized prescribing and monitoring of HC treatment.

DESIGN AND PATIENTS: Serum cortisol profiles were measured in 20 cortisol-insufficient patients (09.00 h cortisol < 50 nmol/l) given oral HC as either a fixed or 'body surface area-adjusted' dose in the fasted or fed state. Endogenous cortisol levels were measured in healthy subjects. Pharmacokinetic analysis was performed using P-Pharm software, and computer simulations were used to assess the likely population distribution of the data.

RESULTS: Body weight was the most important predictor of HC clearance. A fixed 10-mg HC dose overexposed patients to cortisol by 6.3%, whereas weight-adjusted dosing decreased interpatient variability in maximum cortisol concentration from 31 to 7%, decreased area under the curve (AUC) from 50 to 22% (P < 0.05), and reduced overexposure to < 5%. Food taken before HC delayed its absorption. Serum cortisol measured 4 h after HC predicted cortisol AUC (r(2) = 0.78; P < 0.001).

CONCLUSIONS: We recommend weight-adjusted HC dosing, thrice daily before food, monitored with a single serum cortisol measurement using a nomogram. This regimen was prospectively examined in 40 cortisol-insufficient patients, 85% of whom opted to remain on the new thrice-daily treatment regimen.

Definition of adrenal insufficiency:
JAMA -- Adrenal Insufficiency, November 16, 2005, Brender et al. 294 (19): 2528

Discussion of "adrenal fatigue":
Adrenal fatigue: Is there such a thing? - MayoClinic.com

Based on their definition, I would categorize "adrenal fatigue" as a mild form of adrenal insufficiency in which the adrenal glands produce enough cortisol (and other hormones) to sustain life but not enough for optimal physiological function.

 

[CubbieBlue]

Is there any evidence for any type of adrenal fatigue? We know there are varying degrees of hypothyroidism...is there any evidence of a type of hypo-adrenalism? What about a sub-clinical hypo-adrenalism?

 

[Michael Scally MD]

Definition of adrenal insufficiency:
JAMA -- Adrenal Insufficiency, November 16, 2005, Brender et al. 294 (19): 2528

Discussion of "adrenal fatigue":
Adrenal fatigue: Is there such a thing? - MayoClinic.com

Based on their definition, I would categorize "adrenal fatigue" as a mild form of adrenal insufficiency in which the adrenal glands produce enough cortisol (and other hormones) to sustain life but not enough for optimal physiological function.

ChemMan, thank you for the invaluable posts that are helping move this thread discussion forward. It will be important to determine a definition for "adrenal fatigue." Whether this is an acceptable definition will be critical to any form of treatment. It is not possible to have a treatment for an undefined or ill-defined disorder. However, since many do receive treatments for "adrenal fatigue," please post on the glucocorticoid treatment.


The following is the post from the Mayo Clinic link above. Since this is one person's opinion not found in peer-reviewed literature, maybe someone can find a link to a similar sort of evidence for "adrenal fatigue."

Question: Adrenal fatigue: What causes it?
Is there such a thing as adrenal fatigue?

Answer from Todd B. Nippoldt, M.D.

Adrenal fatigue is a term applied to a collection of nonspecific symptoms, such as body aches, fatigue, nervousness, sleep disturbances and digestive problems. The term often shows up in popular health books and on alternative medicine Web sites, but it isn't an accepted medical diagnosis.

Your adrenal glands produce a variety of hormones that are essential to life. The medical term "adrenal insufficiency," or Addison's disease, refers to inadequate production of one or more of these hormones as a result of an underlying disease. Signs and symptoms of adrenal insufficiency include fatigue, body aches, unexplained weight loss, low blood pressure, lightheadedness and loss of body hair. Adrenal insufficiency can be diagnosed by blood tests and special stimulation tests that show inadequate levels of adrenal hormones.

Proponents of the adrenal fatigue diagnosis claim this is a mild form of adrenal insufficiency caused by chronic stress. The unproven theory behind adrenal fatigue is that your adrenal glands are unable to keep pace with the demands of perpetual fight-or-flight arousal. As a result, they can't produce quite enough of the hormones you need to feel good. Existing blood tests, according to this theory, aren't sensitive enough to detect such a small decline in adrenal function — but your body is. That's why you feel tired, weak and depressed.

It's frustrating to have persistent symptoms your doctor can't readily explain. But accepting a medically unrecognized diagnosis from an unqualified practitioner could be worse. Unproven remedies for so-called "adrenal fatigue" may leave you feeling sicker, while the real cause — such as depression or fibromyalgia — continues to take its toll.

 

[hardasnails1973]

ChemMan, thank you for the invaluable posts that are helping move this thread discussion forward. It will be important to determine a definition for "adrenal fatigue." Whether this is an acceptable definition will be critical to any form of treatment. It is not possible to have a treatment for an undefined or ill-defined disorder. However, since many do receive treatments for "adrenal fatigue," please post on the glucocorticoid treatment.


The following is the post from the Mayo Clinic link above. Since this is one person's opinion not found in peer-reviewed literature, maybe someone can find a link to a similar sort of evidence for "adrenal fatigue."

Question: Adrenal fatigue: What causes it?
Is there such a thing as adrenal fatigue?

Answer from Todd B. Nippoldt, M.D.

Adrenal fatigue is a term applied to a collection of nonspecific symptoms, such as body aches, fatigue, nervousness, sleep disturbances and digestive problems. The term often shows up in popular health books and on alternative medicine Web sites, but it isn't an accepted medical diagnosis.

Your adrenal glands produce a variety of hormones that are essential to life. The medical term "adrenal insufficiency," or Addison's disease, refers to inadequate production of one or more of these hormones as a result of an underlying disease. Signs and symptoms of adrenal insufficiency include fatigue, body aches, unexplained weight loss, low blood pressure, lightheadedness and loss of body hair. Adrenal insufficiency can be diagnosed by blood tests and special stimulation tests that show inadequate levels of adrenal hormones.

Proponents of the adrenal fatigue diagnosis claim this is a mild form of adrenal insufficiency caused by chronic stress. The unproven theory behind adrenal fatigue is that your adrenal glands are unable to keep pace with the demands of perpetual fight-or-flight arousal. As a result, they can't produce quite enough of the hormones you need to feel good. Existing blood tests, according to this theory, aren't sensitive enough to detect such a small decline in adrenal function — but your body is. That's why you feel tired, weak and depressed.

It's frustrating to have persistent symptoms your doctor can't readily explain. But accepting a medically unrecognized diagnosis from an unqualified practitioner could be worse. Unproven remedies for so-called "adrenal fatigue" may leave you feeling sicker, while the real cause — such as depression or fibromyalgia — continues to take its toll.

If this is true then people with testosterone levels of 400 with symptoms should also be completely ignored as well?

 

[Michael Scally MD]

If this is true then people with testosterone levels of 400 with symptoms should also be completely ignored as well?

A ridiculous and worthless argument. This apples and oranges! They have no comparison. It is unheard of no reasonable mind would make such a leap in science/medicine.

 

[Michael Scally MD]

I see cortef, etc posted for "adrenal fatigue." How about posting some doses? Is it reasonable to state that individuals are using 20-60 mg/day?

 

[Crazy Crew]

I just started (3days) Medrol 6mg/day/wakeup and have had much improvement. (No afternoon crash)

I could use Cortef 30mg/day =(10mg/wakeup+10mg/4hrs latter + 5mg/4hrs latter + 5mg/4hrs latter)

I have both but would rather dose once or twice a day rather than live by a stop watch.

 

[AlexanderDenmark]

I've used cortisol 20-30 mg a day. I didn't see much improvement, but didn't have any adverse effects either.

 

[zkt]

Cortef is one thing but Medrol isnt to be played with lightly. You can do yourself some serious damage if you dont know what you are doing.

If you think shutting down the feedback between the balls and the rest of the HPTA axis is bad- try fucking up the mechanism relating the adrenal cortex. You will feel bad for a long time. It can easily take six months to get the system working right and on its own after adrenal feedback shutdown. Or so the textbooks say. I have personally tampered with my own enough to have a great deal of respect for the innate biochemical processses.
If one were to take a poll of people taking a standard Medrol Dosepak I`ll bet my bottom dollar they would overwhelmingly report feeling burned out for at least a week after taking the last 4mg.
Since I`m at it.
Important things concerning GC`s:
Medrol is 5-6 times the potency of cortisol
DONT stop Medrol dosing suddenly. Taper it off.The exact titer depends on the starting or maintance dose and the individual and situation.
Once in the morning EOD dosing minimizes the effect on the HPTA.
But if Sx arent controlled then once in the morning ED is the next best thing.
Multiple daily doses will shut down the feedback mechanism fastest.

This stuff is for problems relating to excess immune system activity and not for adrenal fatigue.

MEDROL WILL GIVE YOU ADRENAL FATIGUE
Clear enough?


Not sure about this, Maybe DR.S could comment in how much Medrol constitutes a full replacement dose. The literature is sketchy so I am hesitant to put a number on it. Individual and environmental variation make it difficult.

 

[Testout]

Cortef is one thing but Medrol isnt to be played with lightly. You can do yourself some serious damage if you dont know what you are doing.

If you think shutting down the feedback between the balls and the rest of the HPTA axis is bad- try fucking up the mechanism relating the adrenal cortex. You will feel bad for a long time. It can easily take six months to get the system working right and on its own after adrenal feedback shutdown. Or so the textbooks say. I have personally tampered with my own enough to have a great deal of respect for the innate biochemical processses.
If one were to take a poll of people taking a standard Medrol Dosepak I`ll bet my bottom dollar they would overwhelmingly report feeling burned out for at least a week after taking the last 4mg.
Since I`m at it.
Important things concerning GC`s:
Medrol is 5-6 times the potency of cortisol
DONT stop Medrol dosing suddenly. Taper it off.The exact titer depends on the starting or maintance dose and the individual and situation.
Once in the morning EOD dosing minimizes the effect on the HPTA.
But if Sx arent controlled then once in the morning ED is the next best thing.
Multiple daily doses will shut down the feedback mechanism fastest.

This stuff is for problems relating to excess immune system activity and not for adrenal fatigue.

MEDROL WILL GIVE YOU ADRENAL FATIGUE
Clear enough?


Not sure about this, Maybe DR.S could comment in how much Medrol constitutes a full replacement dose. The literature is sketchy so I am hesitant to put a number on it. Individual and environmental variation make it difficult.

A medrol dosepak is an extremely large amount of cortisol-replacement typically used to suppress inflammation.

I don't think anyone is using amounts like that for adrenal support. Dosing I've seen is more like 4-5mg which would be equal to 20-25mg of cortef.

 

[zkt]

Yea they are.
I dont care what anyone does just so they dont do it to me.
I study these subjects for myself, friends and family and lastly for you guys.
But I feel a moral obligation to post signs along the paths I have travelled.
Take it for what its worth.

I just started (3days) Medrol 6mg/day/wakeup and have had much improvement. (No afternoon crash)

I could use Cortef 30mg/day =(10mg/wakeup+10mg/4hrs latter + 5mg/4hrs latter + 5mg/4hrs latter)

I have both but would rather dose once or twice a day rather than live by a stop watch.

 

[Ozzie]

Medrol is fine if taken at sub-physiological doses and will not shut down the adrenal axis. 4mg medrol is equivalent to 20mg HC and for convenience, i have found it to be a lot more useful -- once in the morning and i'm fine. It is also a reasonable alternative to HC if already predisposed to high blood pressure.

William Jeffries' book, Safe Uses of Cortisol, is a good read and recurringly speaks to the distinction between sub & supra physiological doses. Re: medrol, one also needs to also be careful much past 4 or 5mg/day as bone loss starts to increasingly becomes a concern -- at least, according to Dr. Thierry Hertoghe.

 

[zkt]

There is no such thing as a sub-physiological dose, unless your author is renaming a full replacement dose.
The feedback is not like a switch(digital) it`s analog(contiously variable like the old style volume control).
Your comments re. BP make no sense.
Get a textbook.

Medrol is fine if taken at sub-physiological doses and will not shut down the adrenal axis. 4mg medrol is equivalent to 20mg HC and for convenience, i have found it to be a lot more useful -- once in the morning and i'm fine. It is also a reasonable alternative to HC if already predisposed to high blood pressure.

William Jeffries' book, Safe Uses of Cortisol, is a good read and recurringly speaks to the distinction between sub & supra physiological doses. Re: medrol, one also needs to also be careful much past 4 or 5mg/day as bone loss starts to increasingly becomes a concern -- at least, according to Dr. Thierry Hertoghe.

 

[CubbieBlue]

There is no such thing as a sub-physiological dose, unless your author is renaming a full replacement dose.
The feedback is not like a switch(digital) it`s analog(contiously variable like the old style volume control).
Your comments re. BP make no sense.
Get a textbook.

EVERYONE pins all their cortisol stuff on this one book. Who does this guy cite in his book? YOu would think if this stuff worked and was needed it would be in more than ONE book. Has anyone ever followed up on this book? I think I might buy it just to read it!!

 

[Ozzie]

zkt -- what's with the tonality and rudeness in your reply to me as well as your statement to others on this board "I study these subjects for myself, friends and family and lastly for you guys"

As to your statement 'get a textbook' -- i've actually assembled a rather comprehensive library over the years including the books to which i alluded by Jeffries and Hertoghe.

And yes -- there are indeed sub-physiological doses of HC as there are with other hormones...or would you seriously consider 5mg HC and/or 1mg methylprednisolone sufficient to shut down one's adrenal axis?

And by the very nature of the feedback systems to which you refer -- in the instance of taking HC/medrol (again, at sub-physiological doses mind you), one's hypothalamus will then synthesize less CRH, and in turn, the anterior pituitary will produce less ACTH, and finally -- the adrenal cortex will, in turn, produce less cortisol.

Re: HC vs. methylprednisolone as they relate to mineralocorticoid potency, the former is twice that of the latter...i.e., less salt retention in the case of medrol. Sure -- if one were to take 100 mg of medrol -- his/her blood pressure would rise...but then again, i was speaking to sub-physiological doses.

Cubbie -- i would very much recommend you read the book by Dr. Jeffries -- it's an excellent place to start and while a tad pricey, it's almost half what it cost some years ago.

p.s. -- btw, his work is replete with allusions to the need and benefits of dosing 'sub-physiologically'.

 

[Michael Scally MD]

Cubbie -- i would very much recommend you read the book by Dr. Jeffries -- it's an excellent place to start and while a tad pricey, it's almost half what it cost some years ago.

p.s. -- btw, his work is replete with allusions to the need and benefits of dosing 'sub-physiologically'.

How about stating how much glucocorticoids you use on a daily basis? As far as evidence, can you direct me to a peer-reviewed article supporting the use of these drugs for "adrenal fatigue" or even something vaguely similar? If you have the book, it should be chock filled with references! Finally, I have seen an average or typical HC doses around 20-40 mg/day. Is that about right?