Observations on Weaning Adrenal Hormone Medications Like Hydrocortisone (HC) and Florinef.
This is based on the experience that patients have had with weaning adrenal steroids when applying the circadian T3 method (CT3M). These are not recommendations. They are merely a collection of experiences that have been gathered by thyroid patients in the process of reducing and stopping the use of adrenal steroids like hydrocortisone and florinef.
These observations only apply to those patients who have no fundamental adrenal damage (Addison’s disease) and no hypopituitarism. It is also extremely important that any weaning of adrenal steroids is done under the supervision of a qualified medical practitioner.
When applying the CT3M, adrenal hormones need to be weaned in order to allow the adrenals to receive an adequate request from the body to make adrenal hormones. For cortisol this request comes in the form of ACTH from the pituitary. For aldosterone the request arrives by more subtle routes from the nervous system. However, all forms of adrenal hormones, in synthetic or adrenal glandular form, are ‘the lullaby that sings the adrenals to sleep’. Whilst these adrenal hormones are being taken then the CT3M will not work and the adrenals themselves will not recover.
There is a myth that by taking adrenal hormones the adrenal glands will be rested, and then these steroids may be weaned slowly and the patient’s adrenals will have recovered.
This recovery hardly ever happens. Thyroid patients frequently find themselves fighting continued ill health and unable to stop the use of these steroids. Consequently, the CT3M should be offered as the first choice treatment before any adrenal steroids are considered.
If a thyroid patient is already on adrenal hormones when the CT3M is applied then the following approach for weaning these adrenal steroids has seen to be successful:
1. No adrenal steroids should be taken within the main cortisol production window (the last four hours of sleep). Consequently, the first dose of any adrenal medication should be taken no earlier than when the thyroid patient gets up in the morning (ideally a little later than this). This is to give the adrenal glands a period of time to respond to the circadian dose.
2. Florinef weaning. 100% of any Florinef (which is the synthetic equivalent of aldosterone) and slow potassium should be weaned first before any attempt is made to reduce cortisol-containing medication (hydrocortisone or prednisolone). Florinef affects blood pressure too much to be left in place as the circadian dose is titrated. The CT3M should correct adrenal function if there is no fundamental pituitary or adrenal damage and high blood pressure will result if the CT3M is applied without weaning Florinef at the same time.
3. Thyroid patients have found that Florinef should be weaned in stages with a small fraction of the Florinef being removed at a time as the CT3M is applied. Florinef depresses potassium and if someone is taking slow release potassium then this needs to be reduced at the same time that the Florinef is being weaned.
4. Good results have been seen when Florinef is weaned by quarter tablet reductions, sometimes reducing by a half a tablet every week (1 tablet is 0.1mg of Florinef). Slow potassium should be weaned in proportion. For example for someone on a half a tablet of Florinef and 16 MEQ of slow-K, then they may wean to a quarter of a tablet of Florinef and at the same time reduce their slow-K to 8 MEQ (MEQ stands for milliequivalent). The weaning is based on symptoms and signs and if the Florinef remains too high when the CT3M is applied then it will raise blood pressure very quickly after taking it.
5. So, the CT3M should be applied and the circadian dose titrated as the Florinef and any potassium medication is fully weaned. This may need the support of the patients doctor and at the very least the patients own medical practitioner should be aware of this process and be available to support the patient. Once a circadian dose has been found that seems to help then many patients have found it useful to not change that dose during the weaning of adrenal steroids as too many changes can be confusing and unnecessary.
6. If high blood pressure is present during the weaning of Florinef then the weaning of hydrocortisone (HC) or any cortisol containing medication should also be started at the same time (see points 7 – 10). In this case the first HC dose should be the focus of weaning (points 8 – 9).
7. Hydrocortisone weaning. Once all Florinef and any slow potassium are weaned the next task is to remove cortisol-containing medication, which is often hydrocortisone (HC). HC also depresses potassium and this is another reason to wean all slow potassium before any HC is weaned.
8. HC is normally taken in divided doses during the day. There are several approaches that have been seen to work well:
a) In this approach the first HC dose of the day, which must not be taken during the last four hours of sleep, is delayed or pushed forward in time. The delay should be for as long as feels comfortably possible. If the delay is long enough for the second HC dose to be due then this first HC dose is dropped completely – this could occur immediately if the response to the CT3M is good. If the first HC dose is still needed prior to the second HC dose being due then the first HC dose is trimmed by at least 2.5 mg.
b) An alternative to this approach is to begin by weaning the first dose of the day and at the same time moving it later in the day. Every day or two the first dose of HC may be moved an hour or so later and trimmed by at least 2.5 mg each day if possible. Eventually the first HC dose will be close to the second HC dose and may be dropped totally.
c) The third alternative HC weaning approach is to delay the first HC dose as much as is comfortable and to delay all the other HC doses by the same amount of time. In this approach the last HC dose of the day will end up being later in the day and will be weaned by at least 2.5 mg every time the movement of the doses occur. This approach is more applicable if the thyroid patient appears to need both the first and second doses of HC to remain at the same levels for a little longer as the circadian dose is titrated.
9. By moving the first dose of HC later this creates more time during which the adrenal glands have to support the patient’s body on their own with no suppressive effect from HC (via any lowering of ACTH from the pituitary). This movement later in time of the first dose of HC and the frequent cutting of it by 2.5 mg really allows the adrenal glands freedom to actually work correctly whilst being supported by the CT3M. As the HC weaning is done the circadian dose is further titrated if needed.
10. Once the first HC dose has been moved and effectively dropped then the other doses of HC may be weaned by 2.5 mg or more each day. Eventually, when there is only 10mg of HC adrenal medication being used it may usually be completely stopped.
11. General Observations on weaning of adrenal steroids. It is worth pointing out that during the weaning of steroids that sometimes when a dose of HC or Florinef (or adrenal glandulars if these are being used) is taken that this may produce very marked adverse symptoms. An example of this might be extreme nausea that might follow the taking of a dose of HC or Florinef. When noticeably adverse symptoms occur then this might also provide excellent information that suggests that the adrenal steroid dose is ready to be weaned further.
12. The circadian T3 method should be enabling the adrenal glands to work on their own at this point but further titration of the circadian dose may be required. In some cases the response to the circadian dose when no steroid medication is being used may be too potent because of the suppressing effect of steroids on the adrenal glands.
13. Once the adrenal steroids have been completely stopped then if all symptoms and signs are not normal and suggestive of good adrenal function then the then the circadian T3 method should be re-started with a low dose of T3 (possibly 10 mcg) only 1.5 hours before the time that the thyroid patient gets up. Titrating the circadian dose fully with no steroids present usually resolves any remaining issues. This may need to be repeated over time as the adrenal glands recover. It is important to allow several days in between each change to the circadian dose to ensure the effects can be assessed.
14. This weaning process does not need to take months and months – just four weeks is often sufficient. However, the adrenal glands may not fully recover immediately and a circadian dose may need to be found that supports the adrenals without over-stressing them. Over time the adrenal glands will recover further and twenty-four hour adrenal saliva tests will need to be done from time to time. In some cases the circadian dose of T3 may need to be fine-tuned further. If there is any doubt over what is going on then it may require a re-start of the CT3M, i.e. by using a low dose taken at 1.5 hours before getting up.
The above outline process is based on the experience of many thyroid patients who have successfully applied CT3M and have weaned themselves from adrenal steroids.
For those patients using adrenal glandulars, these may be treated more like the HC weaning part of the above process, with the first adrenal glandular dose being weaned first.
The above process appears to work well, but inevitably it may not be a smooth process because of the powerful nature of adrenal steroids. Having good support in place while this is happening is essential.
It is very important to be aware that even after all steroids have been weaned, the adrenal glands may take a considerable amount of time (weeks or months) to fully recover their ability and that during this time more adjustment may be required to the circadian dose.
However, being completely off adrenal steroids and using the CT3M is a very effective way to enable the thyroid patients’ adrenal gland function to fully return in the cases where there is no Addison’s disease or hypopituitarism.
As stated at the start this is not a set of recommendations and thyroid patients should consult their own medical practitioner if they are considering weaning adrenal steroids.
Best wishes,
Paul
