Adrenal Insufficiency

[hwigston]

5 months ago I wrote a post regarding a recommendation by my Endocrinologist to change from Prednisone to hydrocortisone in order to 'wake up' my adrenals. I was reluctant to change because I have GCA and lost the sight of my right eye and also having read the replies to my pos, advising me against the change. Endo not happy with my decision but ordered a further Synacthen test in 3 months. This took place last week, which showed once more Adrenal Insufficiency (Addison's). Endo once again stressed the importance of changing to hydrocortisone. He said that unless I changed by symptoms of fatigue, lightheadiness etc would not improve. However, I am very confused because my Rheumatologist is telling me to reduce my Prednisone (at present I am on 6 mg reducing by .05 mg per month) and the Endo wants me to take a higher dose of hydrocortison 20 mg, 10 am, 5 noon, 5 at night. Does anyone take hydrocortisone instead of prednisone, or advice on what action I should take would be appreciated.

[Runrig01]

Prednisolone 5mgs = 20mgs of Hydrocortisone. Therefore your endocrinologist is offering a lower dose than you are currently on. Your current 6mgs would mean you would have to take 30mgs hydrocortisone to be equal in dosage.It does however have a shorter half life, hence why Endocrinologist is suggesting splitting dose 3 times a day. Hope this makes sense. In effect Hydrocortisone is still a steroid and as long as you are still taking an equivalent dose it should not cause a problem. Have you discussed this with your Rheumatologist and see what his opinion is, and whether there are any studies looking at hydrocortisones effect on PMR or GCA.

[hwigston in reply to Runrig01]

Hello Runrig. Many thanks for your explanation Prednisolone v. Hydrocortisone. My Rheumatologist stated in his letter that I was doing reasonably well and was happy for me to continue slowly reducing my Prednisone. He didn't question me re changing to hydrocortisone and I didn't think of asking him.

[PMRpro Ambassador]

My granddaughter has asthma and no adrenal function so has hydrocortisone for use when under stress (infections and so on). But she uses both if her pred dose is lower.

As runrig has already explained to some extent, there are various corticosteroids and their effect lasts for varying lengths of time. The pred group (prednisone, prednisolone and methyl prednisolone) are medium acting and their effect lasts for 12-36 hours so are ideal for once daily dosing to achieve the maximum anti-inflammatory effect balanced against side-effect profile (you have a lot of time without pred being present in the body). The effect of hydrocortisone lasts just a few hours so you have to keep "topping up".

polkadotcom also has no adrenal function and will remain on 5mg pred for life. I have to say I don't quite see why the endocrinologist wants you to change from pred to hydrocortisone - it sounds as if it might be his personal preference to use hydrocortisone rather than pred. Are you better at (say) 7mg? If that achieves an improvement in all symptoms maybe that is acceptable to everyone?

However, I have just found this in a paper from 2008 (211.144.68.84:9998/91keshi/..., "Epidemiology, imaging, and treatment of giant cell arteritis, Valerie Devauchelle-Pensec, Sandrine Jousse, Claire Destombe, Alain Saraux. Rheumatology Department, la Cavale Blanche Teaching Hospital, Brest, France)

"When the dosage is down to 7 or 5 mg prednisone equivalent, hydrocortisone replacement therapy and a 1-mg Synacthen test are recommended before treatment discontinuation"

That is pretty much what your endocrinologist wants to do.

[hwigston]

Hi PMRpro. Many thanks for your reply. I have no idea why the Endocrinologist wants to change me from pred to hydrocortisone, except that he said it would 'wake up' my adrenal glands otherwise it could trigger a crisis. I am due to have a repeat of the synacthen test in 2 weeks. Following your reduction programme I should reduce the pred to 5 1/2 next week. As you will see in my comments to Runrig, my rheumy is happy for me to continue with this reduction. I ask myself should I reduce or not. I have no PMR or GCA symptoms at present only symptoms of Adrenal Insufficiency. What would you do if you were in my shoes? Many thanks.

[PMRpro Ambassador in reply to hwigston]

I would contact my rheumy and ask how he feels about it - maybe he and the endocrinologist would get in contact too and discuss the pros and cons. As they should, not sit there and leave the poor confused patient as the dropped tennis ball lying by the net!

Although that research paper is in agreement with your endocrinologist, it is rheumatologists who traditionally care for PMR and GCA so have the most experience with pred reduction in that context. I have not come across anyone on hydrocortisone before and it is the first paper I have found so I imagine that reduction of pred using hydrocortisone in rheumatology is unusual but that it is the way endocrinologists would go.

[hwigston in reply to PMRpro]

Interesting paper especially paragraph recommending using hydrocortisone as a replacement therapy. However I am still not convinced and as you say at the end of the day it's the rheumatologist who is responsible for PMR and GCA so I am staying on my 6 mg until the next time I see him and discuss it again with him. Many thanks for your help. Your comments are always far more helpful than the professionals. I am very grateful to you. Heather

[Runrig01]

I personally would wait till I had the synacthen test results before reducing more. Your adrenal insufficiency symptoms will only worsen, if your own adrenaline glands won't replace the steroid you reduce by you could even be steering yourself towards an adrenal crisis. It sounds from what PMRPRO says about the research paper that your endocrinologist seems to know what he is doing. You seem to be in good hands. Regards, Runrig x

[hwigston in reply to Runrig01]

Hello Runrig. As you will see from my comments above I am going to wait until I see my Rheumatologist which is in 3 months and discuss it with him again. Many thanks for your help and very constructive comments.