RT3-Adrenals Stress dosing

Why it is needed

Healthy adrenal glands produce much more cortisol in response to

stress of any kind. Although less than 30 mg of cortisol is generally

produced each day, during times of extreme stress as much as 300 mg

may be produced. Corticosteroid Binding Globulin (CBG) normally

binds 75 to 80 percent of the cortisol produced; serum albumin binds

an additional 10 to 15 percent. Studies of the response of CBG to

elevated temperatures have shown that the amount of cortisol that is

bound can be reduced to only 50 percent.

So whether it is accomplished by reducing the amount of cortisol that is

bound or by producing more, healthy adrenals provide access to much

more cortisol when needed. This would be true of situations involving

good excitement, unusual or extreme activity or stressful situation such

as illness, surgery, car accident (or even a near miss), travel, family

difficulties, etc.

The adrenals being unable to meet the challenge of producing more

than the usual amounts of cortisol is often when low cortisol symptoms

are first seen. When taking a physiologic replacement dose of

hydrocortisone, the adrenals are relying on the exogenous cortisol and

have no mechanism to respond to unusual stress. Such stress needs

to be addressed with stress dosing.

How to stress dose

Taking additional HC or “stress dosing” can be done by adding 2.5 or 5

mg at the two-hour mark between two regular doses. Depending on the

circumstances and nature of the stress, it may be effective to instead

take the next dose at three hours instead of four. If this is done more

than once in a day, a 2.5 or 5 mg dose can be added in the late

afternoon/early evening. If the stress involves a late night activity

(although late nights should be avoided with adrenal fatigue), an early

evening dose of 2.5 or 5 mg can be added. It is best if any dose late in

the day is at least five or six hours before bedtime and the usual

bedtime dose.

It may take an extra 5 to 10 mg of HC a day, or even double the

normal dose in extreme circumstances, to deal with illness or unusual

stress. Take enough to combat nausea, anxiety or the shakes.

Being a little high in cortisol for a day or two is better than any time

spent too low in cortisol.

Stress dosing may be necessary for any viral infection as viruses tend

to block cortisol in the body. Body aches that accompany a virus are

often caused by low cortisol, so this may be a good indicator. Under

extreme circumstances, the regular dosage rules of no more than 10

mg of HC at one time do not apply.

A small stress dose of HC is preferable to any of the psychiatric drugs

frequently prescribed for anxiety and other symptoms.

Pregnancy

Preferred glucocorticoids during pregnancy are HC or prednisone,

because the placenta inactivates them and thereby prevents exposing

the fetus to excess glucocorticoids. Dexamethasone and

betamethasone readily cross the placenta and can suppress fetal

adrenal function; they should not be used.

The placental inactivation of HC may create a need for increase in

dosing during pregnancy. Studies have shown that levels of

corticosteroid binding globulin increase throughout pregnancy. In

women with intact adrenal function, free cortisol levels also rise

substantially during the third trimester. Therefore, glucocorticoid

replacement should be increased by 50% during the last three months

of pregnancy.

Medical / surgical procedures

An individual who takes HC has special needs in the event of a medical

or surgical procedure requiring anesthesia. The anesthesiologist who

will speak with the patient before any procedure must be told by the

patient that he or she has “adrenal insufficiency.” The HC or other

glucocorticoid being taken should, of course, be included on the drugs

and supplements list that is part of any facility intake forms.

Anesthesiologists generally add 50 or more mg Solu-Cortef to the

patient’s IV.

When fasting is necessary for a medical procedure or surgery that will

require anesthesia, the instructions generally allow necessary

medications to be taken “with a sip of water.” HC taken without food, or

at least a large amount of water, can be irritating to the stomach. If

there is no caveat about using ointments or creams prior to surgery,

hydrocortisone cream can be substituted the morning of the procedure.

Returning to previous dose

If stress dosing is done for more than three days in a row, reduce to the

original regular dose slowly, decreasing the daily amount by 2.5 mgs

every week. Track temperatures and monitor symptoms during this

weaning to make sure stress dosing is no longer needed.