Tips on stress dosing
Many patients find it difficult to get their doctor to prescribe extra cortisol for stress dosing, leaving patients at risk of crisis. We’ve put together some articles and documents that may help open a discussion between patient and physician about the importance of extra steroids during stress and how this helps avoid crisis.
The first resource is the dosing guide from the National Adrenal Disease Foundation, NADF (http://www.nadf.us/tools-for-life/). It’s the first dosing chart we’ve seen that includes dosing recommendations for exercise, fatigue, or emotional stress.
– Download / print PDF: https://www.nadf.us/tools/NADF_Stress_Dosing.pdf
The following paper states “The increased demand for corticosteroids during periods of stress can result in a life threatening adrenal crisis. Education is paramount for patients and caregivers to anticipate, recognize and provide proper early treatment to prevent or reduce the occurrence of adrenal crisis.”
Ashley Grossman, Gudmundur Johannsson, Marcus Quinkler, Pierre Zelissen: THERAPY OF ENDOCRINE DISEASE: Perspectives on the management of adrenal insufficiency: clinical insights from across Europe. Eur J Endocrinol. 2013 Dec; 169(6): R165–R175.
Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805018/
A study into the cause and frequency of adrenal crisis lists stress as the third most frequent cause. “Precipitating causes were mainly gastrointestinal infection, fever, and emotional stress (20%, respectively) but also other stressful events (eg, major pain, surgery, strenuous physical activity, heat, pregnancy) or unexplained sudden onset of AC (7%) were documented.”
Article: http://press.endocrine.org/doi/10.1210/jc.2014-3191
A randomized double-blind cross-over trial showed that patients experience benefits on various aspects of quality of life while on a higher dose (30-40mg) of hydrocortisone substitution when compared to a lower dose (15-20mg) of hydrocortisone. These effects included, with a striking congruence, improved sense of general and mental health, improved physical functioning, fewer symptoms of depression, fewer somatic complaints, less pain and less fatigue. These results emphasize that quality of life is a clinically relevant aspect of HC treatment that needs to be taken into account when individualizing HC substitution therapy.
Werumeus Buning J, Brummelman P, Koerts J, Dullaart RPF, van den Berg G, van der Klauw MM, Sluiter WJ, Tucha O, Wolffenbuttel BHR, van Beek AP: Hydrocortisone Dose Influences Pain, Depressive Symptoms and Perceived Health in Adrenal Insufficiency: A Randomized Controlled Trial. Neuroendocrinology 2016;103:771-778
This article by Professor Bruno Allolio discusses the causes, frequency, and prevention of adrenal crisis. Look at the section on prevention of adrenal crisis half way through. “In emotional or mental stress, I recommend minor dose increases (e.g. 10 mg as an additional dose). For example, in case of a written or oral examination or appearance in court, the additional dose should be taken 1 hour before the event. Some patients report a need for a dose increase in strenuous exercise and such a dose increase is mandatory in otherwise sedentary subjects before exhaustive physical exercise (e.g. a mountain tour for several hours in the unprepared). As a rule of thumb, I am rather liberal concerning minor event-related dose increases and more focused on avoiding chronic over-replacement during standard treatment (e.g. 30 mg hydrocortisone or more).”
Allolio B:Extensive expertise in endocrinology. Adrenal crisis. Eur J Endocrinol. 2015 Mar;172(3):R115-24. Full text article: http://www.eje-online.org/content/172/3/R115.full
We hope these articles can be used to bridge the gap between patient and physician.
Physicians who refuse to be flexible concerning dosages are misunderstanding how the body uses cortisol, and how important it is during times of physical or emotional stress. We must help them understand so they can help us reduce the number of life-threatening adrenal crisis.