Stress dosing

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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.
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.