THE HPA AXIS OR THE TRIO.

[jinasc]

The following is a long post and you may want to copy it or put in your Saved Posts.

It was published in a Newsletter (which is now defunct) and written by PMRpro, this time I actually asked if I could post it on here.

The explanation has been written in language that we can all understand,medical jargon has been excluded. The information has been medically checked out.

The HPA axis or the TRIO................................…

Why you should ask to have a Synacthen test done when you have been on long term Prednisolone and have reduced down to 7.5mg and below.

Adrenal insufficiency can be due to a whole range of things and can also range from total through to just a bit slow to react.

The production of cortisol, which is essential for life, by the adrenal glands is the result of a very complex set of interacting factors which work on both positive and negative feedback and involves the hypothalamus, the pituitary and the adrenal glands, what is called the HPA axis. The thyroid and parathyroid glands also play a part in that the whole range of organs and hormones interact with each other in some way.

Prednisolone therapy can cause total failure of the adrenal glands but usually if you reduce the dose of artificial prednisolone slowly enough they will start to function again in the majority of people, although it may take a year or more.

As long as you are taking prednisolone they are not required to do much just as your central heating boiler doesn't do a lot in the summer because it is warm enough. The presence of any corticosteroid substances in the blood leads the body to think it is well supplied and in some ways it is, prednisolone does the job too, the body isn't that fussy whether it is natural or synthetic steroids that are there. But if you were to stop taking that prednisolone suddenly the body wouldn't immediately be able to produce natural cortisol because of the state of hibernation they are in.

There are various causes of adrenal failure and they are classified as primary or secondary. Secondary failure is due to something other than the adrenal glands themselves causing the problem: there is no ACTH from the pituitary gland for example, or there is already plenty of corticosteroid present in the blood as is the case for people needing to take prednisolone.

Primary failure is the total lack of function of the adrenal glands due to their destruction or inability to function at all perhaps due to genetic causes where the genetic code is incorrect, or illness or infection such as TB or surgical removal/damage for various reasons.

However, the most common cause of primary adrenal failure is autoimmune disease which attacks the glands and damages them so badly they don't work.

Autoimmune disease is a strange thing. Sometimes it is very specific-Type 1 diabetes only attacks the pancreas so it is unable to produce insulin. In other cases there may be a lot of different tissues that are attacked by the immune system - cells in the joints, the gut, the muscles, the nerves or the blood vessels-and in turn this can affect various organs such as the lungs, the kidneys and so on.

In the past links were made between specific signs and symptoms and someone gave them a name - but sometimes people have the signs of one disease and some of the symptoms of another which causes some confusion as a mongrel disease is created - like a dog that has lots of features of one breed but the ears of another and a tail that doesn't look anything else's and new names that describe the findings are used instead. Or it is said to be a “non-specific autoimmune disease”.

For some people who have PMR and need to be on prednisolone it is possible that the underlying autoimmune cause may also be attacking the adrenal glands - but no-one really knows there is a problem until they have problems reducing the dose of prednisolone and stopping. Or the adrenal glands may not have been functioning terribly well anyway - they do degenerate with age, like many other things. But it isn't a certainty.

There are probably no accurate figures about how many people with PMR are unable to get off prednisolone altogether for whatever reason - but figures do suggest that about a quarter will be on prednisolone for a long time and some of them will need it for life. Whether they will eventually get off prednisolone depends on a lot of factors and it may be the PMR is taking a long time to go into remission or the adrenals are just sluggish about waking up - or it might be a lack of adrenal or pituitary function that is to blame.

To identify which it might be would be a research project in itself and require a lot of complex testing - and in most cases all you would end up with is the decision “This patient needs a low dose of prednisolone”. But if you do a simple synacthen test you will know whether a given patient should be able to produce enough cortisol to function and remain well once their dose is low or stopped. If that isn’t likely to happen – they stay at a dose that is enough to keep them well, maybe 5mg or 10mg.

The ACTH test (also called the cosyntropin, tetracosactide, or Synacthen test) is a medical test usually ordered and interpreted by endocrinologists to assess the functioning of the adrenal glands stress response by measuring the adrenal response to adrenocorticotropic

hormone (ACTH;corticotropin).

To do the test you usually attend a hospital clinic – it is more convenient for the medical staff and they can keep an eye on you after the injection although there are very rarely any problems. You should not take any prednisolone in the 24 hours before the test – so you simply don’t take your dose that morning until after the test which is done at 9am. They take a sample of blood to get a baseline level of cortisol and then give an injection which should stimulate the adrenal glands to produce more.

Another blood sample shows if that has happened. Then you can take your usual dose of prednisolone as normal. It can be done even though you are still taking rednisolone every day, the test just has to be interpreted differently, but some doctors are unaware of this.

Our thanks to Eileen Harrison Physiology Bsc(Hons) St Andrews, Medical Science Translator.

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[Longtimer]

Thank you for that, very informative and easy to understand.

[jinasc in reply to Longtimer]

Thank you but it should really go to PMRpro, I just used to twist her arm and still do - my real name is 'a pain in the neck' 🤗😈

[Lochy]

Really helpful and very easy to understand, thanks to you and PMRpro. I will have been here for 7 years next March……really can’t quite believe it! Currently tapering to 3mg the lowest ever. Started Etanercept last January as they think I have more of an inflammatory/sero negative arthritis going on and it has been great. I’d always struggled around the 10-7mg drop.

Apart from bits of OA breaking through things are going well. Hadn’t thought of asking for a Synacthen test but perhaps I should? Never been suggested to me either, but that’s no great surprise!

[PMRpro Ambassador in reply to Lochy]

Do you feel OK? Do you have wobbles?

Asking the GP just for a basal cortisol will provide a lot of information and show if a synacthen test is worth the effort of arranging it. That is a cortisol estimation on a sample taken in the morning between 9am and lunchtime - and if your GP doesn't know how to interpret it - we do!

[Lochy in reply to PMRpro]

I feel absolutely fine (almost as I used to feel all those years ago) apart from the fact I’ve aged 7 years!

If no concerns should I bother?

[PMRpro Ambassador in reply to Lochy]

Not with a synacthen test - if you are having bloods done any time, ask if they will check your cortisol to get some idea how your adrenals are doing.

[MrsNails]

Will add to FAQ’s

[Hidden]

interesting read from you and PMRpro thank you and I am replying reference the AI mention.

My diagnosis is Stills Disease which for me manifests as rheumatoid Disease and is an autoimmune disorder. I have other AI conditions, LS for example. I’ve been unwell for a few months with different and new to me symptoms and mid February had an episode of bad heartburn (etc), lost a stone in weight and feel awful and look ill too.

No face to face appointments here and the WALK-IN CENTRE IS NOW APPOINTMENT ONLY 😠😳 Nurse said ulcer, prescribed omeprazole and tests. Stool tests clear bloods show high cholesterol and very high Amalyse. Speak to Dr who says tests for cancers, ovarian, pancreas....... tests return better results and Dr says I’m anxious about my health? I have told them I have an AI condition that could affect my organs especially liver and pancreas but dismissed. Dr is sending me for gastroscopy and colonoscopy and “any other tests I want” to put my mind at rest. Blooming cheek! I will have the tests of course but feel angry they won’t consider AI involvement.

It could of course be anxiety without me knowing it as I’m not feeling anxious but admit having endured tough months with my Dad and Step Dad both dying on 29th December and my ex husband on 17th February, but I started feeling unwell a month before all that started.

I eat well am a vegetarian, swim and walk when able am 5’1” and was 9 stone 10 but now 8 stone 10 without dieting. I smoked in my 30s and drink far far too much but not a drop for over a month now due to whatever’s going on with me.

Looking back here I realise I’ve been mentioning the same chronic sore throat the whole time during comments without any medical help for it. The merest bit of research shows possible AI links to this and how I feel now and also that chronic tonsillitis can give raised amylase blood levels. I have mentioned my throat to each medical person I’ve spoken to with this current episode but they are not interested but I think it should be considered the culprit and if they looked at it they’d see the state of it. I don’t have neck lumps but do have neck pain and as my Dad died from NHL which AI affected people are more susceptible to I think they should hear me out on this but 5 minutes on the phone does not accommodate this sort of chat.

Raised Amalyse can signal cancers apparently so I understand my Drs comment and tests but am flabbergasted how he can go from testing to rule out ovarian cancer etc to telling me it’s anxiety in the course of two five minute phone calls which started with him saying “why am I speaking to you today”.

[PMRpro Ambassador in reply to Hidden]

I suppose he thinks he is covering the red flag of weight loss with his tests but it doesn't sounds is if he's listening does it? Have you had ANY physical examination?

As for an appointment only walk-in centre - words fail me!

[Hidden in reply to PMRpro]

No examination, just two 5 minute telephone conversations with the locum who has ordered these tests. It does seem mad to me, if he examined me he might say it’s all wind or something easy like that and save the tests for a more serious case instead he scares the willies out of me by doing cancer tests and then infers it’s anxiety. I’m made of stern stuff and not given to wobbles although I appreciate anxiety can be insidious. It’s interesting though as there was no time to tell him of the losses yet he suspects anxiety....... so maybe I’m a snowflake after all ❄️

[PMRpro Ambassador in reply to Hidden]

Really not good enough - and no wonder people are heading off to A&E to e actually SEEN,

Triage by phone is one thing - but you have to know when it isn't enough

[Hidden in reply to PMRpro]

final rant...... it’s the potential waste of NHS resources that gets to me, a physical exam could prevent that, prevent my worry and even prevent the need for blood samples etc the system is broken here.

[PMRpro Ambassador in reply to Hidden]

Well quite - there is no wonder that the ED ends up diagnosing a ridiculous amount of serious illness but unfortunately often a bit late ...