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What Is The Ideal Dose Of Hydrocortisone With High ACTH Levels?
Question: Hi
I have Addison’s disease (autoimmune) since February 2002.
For about 10 years these are my medications:
I take Hydrocortisone 17.5 mg AM and 0.1 mg Fludrocortisones AM + Hydrocortisone 5 mg PM / every day. Fludrocortisones the next day is 0.05 ml then alternates with 0.1mg the following day.
In Oct., 2014 my ACTH, Plasma was 600.4 pg/ml, normal values are 7.2-63.3
In March, 2014 my ACTH, Plasma was 721.4 pg/ml, normal values are 7.2-63.3
In July, 2013, my ACTH, Plasma was 660.2 pg/ml, normal values are 7.2-63.3
I go to my current doctor since 2013. Before that (since 2002) no doctor has ever checked my ACTH.
I was under the impression that it does not make sense to check it since people with XXXXXXX have high ACTH level. My current doctor thinks that my medication dose is low and that increasing the dose will “shut off” the signal my brain sends to the adrenal gland and in turn the ACTH level will become normal 7.2-63.3.
Is that true?
I am reluctant to increase the dose since I have been on it for 10 years and I ASSUME my ACTH level was as high as now during all this years.
Thank you.
XXXX
I have Addison’s disease (autoimmune) since February 2002.
For about 10 years these are my medications:
I take Hydrocortisone 17.5 mg AM and 0.1 mg Fludrocortisones AM + Hydrocortisone 5 mg PM / every day. Fludrocortisones the next day is 0.05 ml then alternates with 0.1mg the following day.
In Oct., 2014 my ACTH, Plasma was 600.4 pg/ml, normal values are 7.2-63.3
In March, 2014 my ACTH, Plasma was 721.4 pg/ml, normal values are 7.2-63.3
In July, 2013, my ACTH, Plasma was 660.2 pg/ml, normal values are 7.2-63.3
I go to my current doctor since 2013. Before that (since 2002) no doctor has ever checked my ACTH.
I was under the impression that it does not make sense to check it since people with XXXXXXX have high ACTH level. My current doctor thinks that my medication dose is low and that increasing the dose will “shut off” the signal my brain sends to the adrenal gland and in turn the ACTH level will become normal 7.2-63.3.
Is that true?
I am reluctant to increase the dose since I have been on it for 10 years and I ASSUME my ACTH level was as high as now during all this years.
Thank you.
XXXX
Brief Answer:
Adequate doses usually normalises ACTH in addisons
Detailed Answer:
Hi XXXXXXX
Welcome to HCM. I had gone through your question and understand your concerns.
Please let me know few more things.
Did you have increased dark pigmentation in skin even now?
How is your serum electrolytes (potassium)?
Have you done a cortisol recently?
What is your weight and height?
High ACTH with low cortisol and increased potassium suggest Addison's disease. The ACTH is produced in response to low cortisol (steroid - hydrocortisone in your case). So if ACTH is still high that means the cortisol in your body is low or rarely the pituitary is producing excess ACTH by its own.
Hydrocortisone is administered thrice daily as the medicine last for only 8 hours. The dose I too feel is slightly low if you are on the obese side.
If I were your treating physician I would have started you on hydrocortisone thrice daily according to your body weight and height. I will monitor ACTH and if it is not coming down I would increase the dose of hydrocortisone or change it to more powerful steroids like dexamethasone or prednisolone. If ACTH is still high on good dose of steroids I would do an MRI of pituitary to see if anything is wrong there.
Hope I have answered your question. If you have any further questions I will be happy to help.
Regards
Dr Ajish TP
Consultant Endocrinologist
Adequate doses usually normalises ACTH in addisons
Detailed Answer:
Hi XXXXXXX
Welcome to HCM. I had gone through your question and understand your concerns.
Please let me know few more things.
Did you have increased dark pigmentation in skin even now?
How is your serum electrolytes (potassium)?
Have you done a cortisol recently?
What is your weight and height?
High ACTH with low cortisol and increased potassium suggest Addison's disease. The ACTH is produced in response to low cortisol (steroid - hydrocortisone in your case). So if ACTH is still high that means the cortisol in your body is low or rarely the pituitary is producing excess ACTH by its own.
Hydrocortisone is administered thrice daily as the medicine last for only 8 hours. The dose I too feel is slightly low if you are on the obese side.
If I were your treating physician I would have started you on hydrocortisone thrice daily according to your body weight and height. I will monitor ACTH and if it is not coming down I would increase the dose of hydrocortisone or change it to more powerful steroids like dexamethasone or prednisolone. If ACTH is still high on good dose of steroids I would do an MRI of pituitary to see if anything is wrong there.
Hope I have answered your question. If you have any further questions I will be happy to help.
Regards
Dr Ajish TP
Consultant Endocrinologist
Above answer was peer-reviewed by :
Dr. Yogesh D
Dr. Ajish,
Please see my responses.
Did you have increased dark pigmentation in skin even now?
My answer is “No”, naturally I have a little darker skin than other white people.
How is your serum electrolytes (potassium)?
Oct 2014: 4.4 mmol/L, normal range is 3.5 – 5.2
March 2014: 4.3 mmol/L, normal range is 3.5 – 5.2
July 2013: 4.8 mmol/L, normal range is 3.5 – 5.2
Have you done a cortisol recently?
Oct 2014: 37.3 ug/dL, normal range is 2.3 – 19.4. So strangely enough it is high rather than low. There was not difference in medication but see one difference under the "Note" below.
March 2014: 0.2 ug/dL, normal range is 2.3 – 19.4 This one would agree with you said.
July 2013 not avaialble
What is your weight and height?
Weight: 155 lbs
Height 5’9”
Note: All blood test were done fasting around 8:30am but the March 2014 and July 2013 tests were done before taking the medication (hydrocortisone and fludrocortisones) while the October 2014 blood test was done fasting but after taking the medication that morning as indicated by the doctor. Previously I thought fasting meant not to take the medication either.
The other results out of range are Hemoglobin A1c: 5.9, normal range is 4.8-5.6.
And LDL Cholesterol calc: 106 mg/dL, normal range is 0-99.
Thank you
XXXX
Please see my responses.
Did you have increased dark pigmentation in skin even now?
My answer is “No”, naturally I have a little darker skin than other white people.
How is your serum electrolytes (potassium)?
Oct 2014: 4.4 mmol/L, normal range is 3.5 – 5.2
March 2014: 4.3 mmol/L, normal range is 3.5 – 5.2
July 2013: 4.8 mmol/L, normal range is 3.5 – 5.2
Have you done a cortisol recently?
Oct 2014: 37.3 ug/dL, normal range is 2.3 – 19.4. So strangely enough it is high rather than low. There was not difference in medication but see one difference under the "Note" below.
March 2014: 0.2 ug/dL, normal range is 2.3 – 19.4 This one would agree with you said.
July 2013 not avaialble
What is your weight and height?
Weight: 155 lbs
Height 5’9”
Note: All blood test were done fasting around 8:30am but the March 2014 and July 2013 tests were done before taking the medication (hydrocortisone and fludrocortisones) while the October 2014 blood test was done fasting but after taking the medication that morning as indicated by the doctor. Previously I thought fasting meant not to take the medication either.
The other results out of range are Hemoglobin A1c: 5.9, normal range is 4.8-5.6.
And LDL Cholesterol calc: 106 mg/dL, normal range is 0-99.
Thank you
XXXX
Brief Answer:
Increase dose of hydrocortisone and fludrocortisone
Detailed Answer:
Hi XXXXXXX
Thanks for providing the details
1. Increase in pigmentation is associated with Addisons disease. This is due to high ACTH which will come down with steroid treatment. It is a clinical clue for under replacement. So it is good that you don't have increased pigmentation.
2. Your potassium is occasionally high. In my patients with Addison's I try to keep the potassium below 4.5 especially if there BP is below normal. I also prefer the same dose every day. So I suggest you to take Fludrocortisone 0.1 mg every day after consulting the doctor. Check potassium periodically and keep it in 3.5-4.5 range.
3. The hydrocortisone dose for your body weight and height is 18 - 27 mg/day. You are currently taking 22 mg/day. I suggest you to increase the dose to 27 mg/day and split it o 3 divided doses - 12.5-5-10 mg after consulting a doctor. Please check the ACTH after 1 months and if it is not coming down we have to change the type of steroids.
4. Cortisol blood tests can be done before or after the steroids. But you should inform the doctor how it was taken. The interpretation of values will be different. Before medications it has to be on the lower side of normal. The high value that you got is after medications -you are taking a higher dose in morning.
5. Your other lab reports show pre diabetes and borderline elevated LDL. No medications needed at present. Have diet and exercise modification and repeat test after 3 months.
Hope I have answered your question. If you have any further questions I will be happy to help.
Regards
Dr Ajish TP
Consultant Endocrinologist
Increase dose of hydrocortisone and fludrocortisone
Detailed Answer:
Hi XXXXXXX
Thanks for providing the details
1. Increase in pigmentation is associated with Addisons disease. This is due to high ACTH which will come down with steroid treatment. It is a clinical clue for under replacement. So it is good that you don't have increased pigmentation.
2. Your potassium is occasionally high. In my patients with Addison's I try to keep the potassium below 4.5 especially if there BP is below normal. I also prefer the same dose every day. So I suggest you to take Fludrocortisone 0.1 mg every day after consulting the doctor. Check potassium periodically and keep it in 3.5-4.5 range.
3. The hydrocortisone dose for your body weight and height is 18 - 27 mg/day. You are currently taking 22 mg/day. I suggest you to increase the dose to 27 mg/day and split it o 3 divided doses - 12.5-5-10 mg after consulting a doctor. Please check the ACTH after 1 months and if it is not coming down we have to change the type of steroids.
4. Cortisol blood tests can be done before or after the steroids. But you should inform the doctor how it was taken. The interpretation of values will be different. Before medications it has to be on the lower side of normal. The high value that you got is after medications -you are taking a higher dose in morning.
5. Your other lab reports show pre diabetes and borderline elevated LDL. No medications needed at present. Have diet and exercise modification and repeat test after 3 months.
Hope I have answered your question. If you have any further questions I will be happy to help.
Regards
Dr Ajish TP
Consultant Endocrinologist
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Above answer was peer-reviewed by :
Dr. Shanthi.E
Answered by
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