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12/20/2011 04:45 PM

What do YOU think AM Cortisol and ACTH levels

DukeNLucyPosts: 200

Some of you may know my background. I had a base of brain tumor removed 20 years ago, where some had to be scraped off the Pit. This year, starting in the spring, I began having symptoms of easy fatigue/exhaustion, nausea/vomiting, urinary incontinence, lower back pain, and weight loss.

Around August I had three epidural shots of Dexamethasone in my lower back; these were each spaced 2 weeks apart. These were for inflamed nerves from spinal stenosis and disc bulge, and were thought to also be the cause for the incontinence.

At the end of Sept I saw an Endo to see if a root cause could be found for the increasing symptoms of daily fatigue and nausea. Labwork gave a morning and afternoon Cortisol level of 0.6, and ACTH <5. I didn't tell the Endo about the previous back epidural shots – simply because I'd totally forgotten about them. The Endo diagnosed me with SAI, started me on Prednisone, and a couple weeks later, Levothyroxine. A MRI scan was negative.

It took about 6 weeks after starting the Pred that the daily constant nausea started to go away. When I learned on MDJ that steroids could cause Induced SAI, it made me think of the Dex shots I had had, and that possibly they were the real cause of the SAI. I switched Endos, and the new one also thinks I may have Induced SAI. To test her suspicions and rule out autoimmune causes, the following bloodwork results a couple weeks ago were reviewed:

Prolactin, Serum 6.7 ng/mL (post menopausal 2.0-20 ng/mL

LH, Serum 32 mIU/mL (Post menopausal 10-54.7 mIU/mL)

FSH, Serum 46.9 mIU/mL (Post menopausal 23-116.3 mIU/mL)

Estradiol 12 pg/mL (post menopausal <= 27 pg/mL)

IGF-I, LC/MS 281 ng/mL (50-317)

Thyroid peroxidase AB <10 IU/mL (<35)

Thyroglobulin AB <20 IU/mL (<20)

T4 Free, Nondialysis 1.0 ng/dL (0.8-1.8)

TSH 1.54 mIU/L (0.4-4.5)

Vit B12, serum 370 pg/mL (200-1100)

Vit D, 25-OH, Total 40 ng/mL (30-100)

The Endo thinks these indicate the Pit is probably working just fine. She wants to keep me on the Levothyroxine, but start to slowly taper off the Pred. To do that, I'm taking 5 mg Pred every morning, and every other day take 2.5 mg Pred in the afternoon.

Bob here has said there's been a few cases on MDJ where people have had Induced SAI. If they're anything like me, it happened because I was unaware of the strong long-lasting effect on the endocrine system that steroids can have, even with small dosages found in skin lotions, nasal sprays, and inhalers. Steroids used to treat misdiagnosed SAI could hide other medical issues so they're not properly diagnosed, and as we all know, tapering off steroids can cause havoc on your system. Right now what is the true cause for my symptoms is unclear, especially since some bouts of nausea/vomiting have returned after the tapering began.

To further test how well the Pit and Adrenals are doing, the Endo now wants to get a morning cortisol level and ACTH level, provided the previous day afternoon dose of pred is skipped, and that day's morning Pred dose is skipped as well (meaning 24-hr with no Pred before the bloodwork is drawn).

So here is what can be confusing. I know we are not doctors, but still, what do YOU think are answers to the following 3 questions?

1. If my Adrenals and Pit are no longer affected by the autumn Dex shots, what kind of negative feedback effect on the HPA axis has my daily Pred dosage been giving?

2. Will any leftover Pred in my system (from 24-hr with no Pred) have any effect on the morning Cortisol levels and ACTH levels? What could I expect the levels to be?

3. For curiosity sake, what could the morning Cortisol and ACTH levels be like if the Pred dosage wasn't skipped at all, or even if the morning dose of Pred had been taken 2 hrs before the levels were drawn??


Post edited by: DukeNLucy, at: 12/20/2011 04:46 PM


12/20/2011 07:21 PM
Posts: 772

Yes, prednisone is going to affect your HPA system. BUT, the 24 hours without any, I would think, will be stressing your system a bit and will be asking your system to work a bit and put some out. The every other day bit is a normal pulse system for getting the adrenals/keeping the adrenals working in rhuematology. I have no idea what the levels are going to say, but I would suspect that taking any that am would immediately decrease the cortisol/acth level - even 2 hours later - prednisone is just starting to get going then, and lasts up to 24 hours. I kind of like new endo - I'd go along with her for now.

12/21/2011 11:15 AM
bob3bob3Posts: 4213
Senior Member

About cortisol half lives and decay rates.

This is my somewhat fragmented knowledge set. If anyone had good bio knowledge of this please speak up! Warning, super science waffle follows!

- Hydrocortisone goes in as cortisol

- Prednisone gets metabolized to measurable cortisol

- Dexamethasone does something different. On one hand it HPA suppresses cortisol production yet it can be used as a stim test alternate metabolism support. I think the differences is in the bindings, but I need more learning on this.

- Half life is dependent on what you are measuring. Generally speaking the "biologic" or duration of action half life goes something like 8hrs for HC, 16-36hrs for Pred and 36-54hrs for Dex. This is however the downstream metabolic and cellular effects etc, not the blood cortisol level that is measured for stims etc. That peaks between 30 and 90 minutes after ingestion and half life/levels at around 120-240 minutes. That wide range is usually a function of concurrent eating that slows the stomach uptake.

- Calculating the remaining level from ingested HC shouldn't be too difficult except you really don't know what the peak cortisol value. If we assume that the HC pill takes you close to blood CBG saturation for a short period of time (say 25ug/dL serum) then every time you add 3 hours it will roughly halve the level. At 15 hours for example your initial 25ug/dL is now about 0.6ug/dL. It is worth mentioning that in terms of early morning stim and serum tests, the HC dose the afternoon before will be far less than the saturating maximum in line with the diurnal curve we try to match. This makes the numbers maybe half or 0.3ug/dL. This error can be allowed for in results as a worse case situation. Keep a mind that the error bars can be pretty wide the further halving's there are.

- I don't have any breakdown rates on Prednisone. In terms of AI end use though it seems roughly double to three times that of HC in how long it "lasts" so you might argue that at 15 hours the worst case remaining cortisol is back up at 0.6-0.9ug/dL. We don't however know this for sure. The "unbroken down" Pred may hang around for longer before the cortisol is subject to the decay rate above.

- This all boils down to comparing the measured cortisol and subtracting the worst case error. If you were 6ug/dL the error could just put you out of refrange. If (like me) you are consistently 1.5 then you are obviously still cortisol deficient regardless of the error. (JFI I was about 1.0 in my last test, under the influence of Dex. Its also important to know that this was below the limits of measurable accuracy. ie it was written <28nmol/L)

- My best wild guess is that 15Hrs post Pred should allow maybe 1ug/dL. 24Hrs will be around 0.1ug/dL. Since one usually takes the 2nd Pred dose at 3PM and gets tested at 9AM, 18 hours (0.5ug/dL) would be more likely if you didn't skip that dose.

- Okay now read it back to me. There will be a test next Monday...


12/21/2011 04:05 PM
NymphPosts: 231

DukeNLucy, I hope that your new endo can figure it out!

Now I'm curious... steroid nasal sprays and creams can cause SAI? I was on Flonase for a year and a half until last March or April. I stopped because I was getting nosebleeds. I still get them, permanent hole in the nose I guess. Most of my symptoms that cause me to suspect an HPA problem predate this, however, my heart palps and arthritis symptoms started after I quit the Flonase, I think. Dose this mean anything at all? I thought that Flonase was not supposed to be systemic...

12/21/2011 05:09 PM
bob3bob3Posts: 4213
Senior Member

Its a quantity thing. Low dose asthma/nasal steroids shouldn't cause systemic effects. Its also a function of glucocorticoid half life. In the early days of Pulmicort (Budenoside) though it was common to prescribe in the order of 1600ug/day which is enough to cause systemic and SAI effects. Off the top of my head I think that's "worth" about 10mg of Pred. Those that use Pulmicort now usually only take 1/4 or so of that dose.

You might try nose saline? I seem to remember in my case the nosebleeds seems to abate somewhat as well as a reduction in allergic situations. I have no idea why!

12/22/2011 05:36 AM
NymphPosts: 231

Thanks, that makes sense. I do use a neti pot to irrigate my nose every day, twice a day when I'm sick! Usually the nosebleed starts before I irrigate, and I haven't noticed an improvement except for every other nasal/sinus symptom!

12/22/2011 07:58 PM
DukeNLucyPosts: 200

Thanks everyone, for your feedback. Bob - I like your numbers! When the discussion of induced SAI came up a few weeks ago, I posted some links to research articles regarding dangers of steroids to the endocrine system, most notably how they can have a longer lasting effect than what many realize. And as Bob said, much depends of the type of steroid used and it's half life, as well as the amount.

I'm finding getting ready for Christmas and the rise in stress at work is enough to make me not do very well in tapering off of Pred. I'm exhausted more often than usual and have repeated episodes of brain 'Duh' or brain 'Fog'. Plus the bouts of nausea - most often in the morning before eating, drinking, or taking meds. And the aches and joint hurts! My gut feeling is that my body wants more Pred instead of less. I may give in to that and quit the skippping of afternoon doses for the next few days, until right after Christmas, and then restarting the tapering on Tuesday.

I'll be good and call the Endo office tomorrow and check that this temporary upped dosage is ok. If I want to maintain a good rappport with my new Endo, I need to do my part and attempt to maintain a good Dr-Patient relationship. Hopefully she will understand - the idea of me making cookies, sweet potato casserole, wrapping gifts, traveling, and being with family - it just seems like way too much to handle! I'd rather skip it and just crash somewhere - be near the fun but not be an active participant. And that really is not like my old self! I used to be the energetic, fun-loving, goal-driven risk taker who liked to stretch the limits of whatever I was doing. Right now I'll be glad when the holidays are over!

Anyway, I'm going to hold off getting the morning cortisol and ATCH levels until later next week. I'm hoping they show the adrenals are OK; my body 'wanting' more Pred right now could be just like having an addiction - when the body likes something, it just wants to continue having it, or even want more, regardless if it is truly needed or not. It rebells being forced to taper off!

12/23/2011 10:54 AM
NymphPosts: 231

I hope that slowing down the taper helps you enjoy the holiday. Merry Christmas!

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