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

mgs 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

mgs 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 mgs can be added. It is best if any dose late

in the day will be at least five or six hours before bedtime and the usual

bedtime dose.

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

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

when ill. Take enough to combat nausea or anxiety or the shakes.

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

spent with too low 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

mgs 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 hydrocortisone or

prednisone, because the placenta inactivates them and thereby

prevents exposing the fetus to excess glucocorticoids.

(Dexamethasone and betamethasone readily cross the pacenta and

can suppress fetal adrenal function, and so should not be used.)

The placental inactivation of hydrocortisone may create a need for

increase in dosing during pregnancy. (Studies have shown that levels

of cortisol-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 hydrocortisone 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 mgs 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 back

to the original regular dose slowly, reducing 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.