How to treat adrenals–for the patient and their doctors
NOTE: this page is simply meant to provide information, NOT to replace the relationship between you and your doctor. You are responsible for the results or consequences of your choices based on general information presented here. Please consult with your doctor.
Though this page tells you what we’ve learned about using cortisol for adrenal insufficiency via information from a few doctors and excellent books, your ultimate goal is to find the amount that’s right for YOU. That’s the amount that finally gets thyroid hormones from your blood to your cells, which in turn will stabilize your temperatures (as outlined in Discovery Step Two on the Adrenal Info page), as well as allows your sluggish adrenals to rest.
Doctors we admire have stated that after you’ve held the above goals for a few months or up to a year, you can then attempt to slowly WEAN OFF to allow your adrenals to kick back in. Some of their patients take longer than others to achieve this, i.e. more than year, depending on the severity of their insufficiency.
When you have confirmed sluggish adrenals, whether via the self-tests, your doctor’s knowledge, or the 24 hour adrenal saliva test, it can be time to talk to your doctor about cortisol support, whether Isocort or Hydrocortisone like Cortef–the latter which patients find to work the best. Below is a dosing schedule developed by Valerie, the moderator of the Adrenals Forum, and which leads to 4X a day dosing. It’s listed by milligrams for those using Isocort, but can be used for HC (Cortef), as well, and with your doctor’s approval and guidance. Since there is doubt that Isocort actually contains 2.5 mg per pellet, you may need more to reach the the actual 20 mgs:
Day 1-3: 2.5 mg first thing in the AM (2.5 mg total)
Day 4-6: 2.5 mg first thing, 2.5 mg in four hours (5 mg total)
Day 7-9: 2.5 mg first thing; 2.5 mg in four hours; 2.5 mg in four hours (7 1/2 mg total)
Day 10-12: 5 mg first thing; 2.5 mg in four hours; 2.5 mg in four hours (10 mg total)
Day 13-16: 5 mg first thing; 5 mg in four hours; 2.5 mg in four hours; 2.5 mg bedtime (15 mg total)
Day 17-20: 10 mg first thing; 5 mg in four hours; 2.5 mg in four hours; Bedtime 2.5 mg (20 mg total)
NOTE: some patients have adrenal fatigue so severe that doctors may end up speeding up the above schedule a bit. Additionally, some patients may find they need to dose every 3 hours rather than 4.
Since Day 13-16 puts you on 15 mgs cortisol, and if adrenal testing didn’t show your low cortisol to be severe, you can choose to stop here and see how well the Armour is now getting into your cells, which can be revealed by non-fluctuating temps. If low cortisol signs still persist on 15 mgs, you can raise to 20 mgs and see, which is an amount that Dr. Peatfield shoots for at the minimum with most patients (see good information below from Peatfield). Note that many patients seem to end up in the 20-30 mgs range, but it’s a good minimum to shoot for.
WHAT IF I’M ALREADY ON ARMOUR WHEN I START USING CORTISOL: If you are already on Armour when you start cortisol, patients and their doctors have discovered that they need to decrease their Armour a bit at the same time they are increasing cortisol to prevent a “dump” of thyroid hormones from their blood to their cells when the right amount of cortisol is reached. If you do get the dump of thyroid hormones from your blood to your cells, it feels like hyper with extreme anxiety, racing heart, and/or other uncomfortable symptoms. If you feel this discomfort, even after decreasing the Armour, patients find it helpful to stop the Armour completely for a day or two or more, then raise back up.
WHAT IS MY GOAL WITH ADRENAL SUPPORT: Patients have learned that they have to reach two goals for adrenal healing to work: one, to find the dose of cortisol which gets the thyroid hormones to the cells and helps rest the adrenals, followed by two, the right amount of desiccated thyroid to remove hypothyroid symptoms, which in turn takes the strain off the adrenals. When they have achieved BOTH, they hold both for at LEAST for 6-8 weeks, and often months into a year or more. They then start the slow weaning process, allowing the adrenals to kick back in slowly, such as 2.5 mgs a week less. Stress dosing may be necessary.
WHAT DO I LOOK FOR WITH MY ADRENAL SALIVA RESULTS: Generally, individuals with healthy adrenals will have the 8 am reading in the upper part of the range, if not slightly over. The noon reading with strong adrenals will also be in the upper part of the range, but not quite as high as the morning. The afternoon result will be a bit lower, and the midnight result will be at the bottom of the range, which allows you to sleep, just as the high morning reading helps you wake up refreshed
WHY SALIVA INSTEAD OF A BLOOD or URINE TEST: Cortisol levels can vary during the day–you can be optimal at one time of the day, and low at other times. Using blood-only tests one time during the day. Urine can also be inadequate since it simply gives you an average of a total 24 hour period. Saliva, on the other hand, will test you four times–generally 8 am, noon, 4 pm and midnight. And there’s a bonus with saliva—you don’t need a prescription, and you can get more accurate results in a non-stressed environment such as your home! You should also share the results with your physician. See the labs on the Adrenal Info page, or the Recommended Labwork page.
HOW MUCH CORTISOL DO I NEED AND HOW DO I TAKE IT: If your adrenal saliva results reveal low readings, or you have very obvious low cortisol symptoms such as anxiety, overriding fear, pupils that don’t stay constricted, and/or fluctuating temps from day to day, etc., we have learned that patients usually need at least 20 mgs. cortisol, which according to Jeffries, “takes the strain off of the residual adrenal tissue and provides for more functional reserve in times of stress”. Occasionally, we see doctors prescribing up to 25-30 mgs of cortisol support before the patient finds success. The reason–they may be metabolizing their cortisol faster, and/or need more doses closer together. Or, you may have poor digestive issues due to your hypothyroid. You and your doctor will know you have found your optimal amount of cortisol when your temps from day to day aren’t fluctuating anymore (see Self Test #4 on the Adrenal Info page), and when you note relief of certain symptoms (because the thyroid hormones are now getting to your cells.) You may still have to raise your desiccated thyroid.
Again, patients have learned that it’s also important to dose cortisol no less than 4 times a day, since cortisol is used up fairly quickly. And some individuals will need to dose even more and closer together. Additionally, you will want to mimic the cortisol rhythm, which equates to your highest amount first thing, and subsequently lower amounts throughout the day.
WHAT IF I CAN’T AFFORD THE SALIVA TEST: Overall, the adrenals saliva test is reasonable. But if you can’t afford it, but strongly surmise sluggish adrenals based on the over-reactions you had to low doses of Armour, and DISCOVERY STEPS ONE AND TWO HERE, you can safely experiment with cortisol support and with guidance from your physician, according to doctors we respect, such as raising to 15 mgs. as shown above, and keep that for several days….then see if you can tolerate Armour again. If not, you may need to raise to 20 as outlined, before you tolerate Armour. Some patients have to go to 25 and occasionally 30 mgs, and dosing closer than every four hours, before they achieve success. It’s individual. For very severe low cortisol issues, the theory is that lowering the ACTH is the key to healing the adrenals. But everyone should at least try the lower doses.
WHEN I DO THE 4 TIMES A DAY OR MORE DOSING, SHOULD I TAKE THE FINAL DOSE AT BEDTIME: Some patients find it helpful to take that final amount at bedtime to help them sleep, but it’s individual.
IF I AM NOT YET ON DESICCATED THYROID, HOW LONG DO I USE THE CORTISOL BEFORE I START ARMOUR: If you are not on natural desiccated thyroid when you start cortisol, talk to your doctor about following the schedule above, and after two weeks, or at the very least when you get up to 15 mgs, it appears to be safe to start on one grain or less Armour without having reactions. After starting Armour or other desiccated thyroid, raise it in small amounts every few weeks to take the stress off your adrenals.
DO I NEED EXTRA CORTISOL DURING STRESSFUL SITUATIONS: Healthy adrenals would produce extra cortisol in times of physical or emotional stress. So, if you have to undergo a stressful event, or even have a sickness, patients found it wise to “stress-dose”, which is adding more cortisol to each of your daily amounts, such as 2.5 to 5 mg.. If you have a severe illness like the flu, that stress dose amount can end up being up to 20 mg each time.
Jeffries states: In events of stress, “higher dosages of cortisol are required to maintain a physiologic state that would produce hypercortisolism with it’s well-known undesirable effects in the unstressed states. The increased secretion of adrenal hormones serves to meet an increased need during stress and tends to maintain homeostasis rather than to disturb it. The increased secretion does not cause a state of hypercorticism such as develops when the titer of these hormones is increased artificially in the absence of need. Hence, a patient with adrenal insufficiency under stress may require dosages of cortisol to maintain a physiologic state that would produce hypercortisolism with its well-known undesirable effects in the unstressed state. This higher amount can be up to double what you would normally take daily.”
After the illness or short term extreme stress subsides, you then start to taper down to your original doses.
It’s also worthy to note that if you are having to stress dose quite often during a week’s period, you may simply not be on enough cortisol overall.
WHAT CAN I DO ABOUT THE NAUSEA I FEEL WHEN USING CORTISOL: Patients have learned that taking cortisol with food can help prevent stomach upsets.
WHY ARE MY HIGH LEVELS OF CORTISOL SUPPORT NOT WORKING FOR ME? Some patients have been guided by their doctors up to 30-40 mg of HC daily, yet they are not getting good results. We have learned that low aldosterone may be an issue to explore. Additionally, some patients metabolize HC faster than others, so the solution is to space your HC doses closer together than the recommended 4 hours between doses. We have also found doctors who switch their patients from HC to Methylprednisolone with the brand name of Medrol to achieve better results, since Medrol metabolizes more slowly and is longer acting.
WHAT IF MY CORTISOL LEVELS ARE ONLY MINORLY LOW, OR I WANT TO AVOID THE USE OF CORTISOL? Another option to prevent a slide into more serious adrenal fatigue is the use of licorice root, which reduces the breakdown of active cortisol to inactive cortisone. A rare side effect is high blood pressure but again…it’s rare. Go here for more good info on licorice root.
WHAT DO I NEED TO REMEMBER: In folks with healthy, non-sluggish adrenals, their adrenals give them the amount of cortisol they need automatically. So for those with sluggish adrenals, your goal with adrenal support is to give back to your body what your adrenal insufficiency can’t give. And sometimes it’s a guessing game, but you will come to know your body and how it feels. Additionally, the purpose of adrenal support is to help your adrenals to hopefully REST AND RECOVER. Generally, once you have been on an ideal amount of adrenal support for several months and more, AND HAVE FOUND YOUR OPTIMAL DOSE OF ARMOUR (which takes the stress off the adrenals), you will want to consider a slow decrease of your adrenal support to allow your own adrenals to kick back in. During this time, it’s wise to be on Vit. C., since the highest concentration of ascorbic acid in the body occurs in the adrenal cortex. Giving your body Vit. C helps the adrenals to function better, and supports them. This is ALSO true with sea salt. Dr. Brownstein recommends 1/4 to 1/2 tsp in good water per day…Dr. Wilson advocates that numerous times throughout the day. Again, just be sure to drink at least an 8-10 ounce glass of good water (no fluoride or chlorine, if possible, since we get too much of both) for each 1/4 to 1/2 tsp you take. One patient likes taking 1/4 - 1/2 tsp. in about half a cup of water, and then follows that with a big glass of water.
WHAT IF UPON TAPERING DOWN MY CORTISOL, I GET UNCOMFORTABLE: If, upon a slight decrease, you find symptoms returning, it’s a sign you need to hold your optimal adrenal support a bit longer. So you can go back up to your former cortisol dose, hold, and try a decrease later on. Thyroid patients on cortisol have learned that the wean has to in small amounts, and very slow.
The following comes from Peatfield’s book Your Thyroid and How to Keep It Healthy:
Page 122, Your Thyroid and How to Keep it Healthy:
Once the hydrocortisone is started, the full support dose is now built up to effective levels over two or three weeks….spread out through the waking day. The reason (to spread the doses out throughout the waking day) is that it is not stored by the body and gets rapidly used; two or three hours will see it pretty well used up completely. Since a smooth level of support is desirable, the dose needs to be spread out. The final dose is usually 20 mgs daily, that is half a tablet four times a day; but careful adjustment relating to the response may take the dose to 25 or 30 mgs daily, exceptionally even 40 mgs. These higher doses are related more to absorption in the stomach than to deficiency, but low adrenal reserve reaching Addisonian levels may make such doses necessary.
And on page 123:
The length of time necessary to provide adrenal support is really very variable. My normal practice has usually been to obtain the best result with thyroid and adrenal support, and after six or eight weeks {of having optimal thyroid support with optimal cortisol support], start to tail off the cortisone supplement. If there is no adverse results, it may then be stopped–taking, say four weeks in the process. Sometimes, the patient starts to lose ground; and you then have the choice of replacing it with a glandular concentrate for a longer period or restarting the cortisone, and in another eight weeks or so another attempt to tail it off is made. Sometimes, the adrenals have been so badly hit that the adrenal support may be required for months, and if the adrenal glands never fully recover, for a more indefinite time. Again, I emphasize that if adrenal support is required, it must be given for as long as it takes; there is no risk to this since one is simply restoring the situation to normal, in the same way, and for the same reason, that thyroid support may have to be given indefinitely.
To see this chapter from Peatfield’s book in it’s entirety, go here.
FINAL REMINDER: As mentioned by Peatfield and as observed in patient experience, remember that those on adrenal support have TWO goals. First, to find the amount of cortisol that gets the thyroid hormones from the blood to the cells and stops your fluctuating temps, and second, to be on an optimal amount of Armour. If you don’t achieve both, adrenal rest and healing can be delayed.
WHAT IF MY CORTISOL IS HIGH AT NIGHT: Generally, those with high nighttime cortisol are going to have low morning or noon cortisol. So being on the scheduled cortisol above is going to eventually correct the high nighttime cortisol. In the meantime, try supplementing with 300-800 mg. Phosphatidylserine aka PS. Take it before bedtime. You may need to be on the higher end of the range above to lower it. To read even more about PS, click below:http://qualitycounts.com/fpps.html Another patient has been able to lower her nighttime cortisol by taking Melotonin before bedtime. It may take several weeks before you notice the difference.
Click here to read the most FREQUENTLY ASKED QUESTIONS about adrenal support.
Click here to read a thyroid patient’s ongoing journey with adrenal fatigue.
Go here to understand the 7 stages of adrenal fatigue. You will see that some stages mean you have levels all over the place before they all come down.
Note: When I have done an unofficial poll, as high as 75% of those who participated had confirmed adrenal insufficiency. It’s common. Janie
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