Since the subject of bigger am or pm dose has come up again, I thought that some of you might be interested in a paper called "Home Monitoring of 17 Hydroxyprogesterone Levels in CAH With Filter Paper Blood Samples" by H. Bode and S. Rivkees, et. al. An abstract can be found at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9931527&dopt=Abstract and the full article in the Feb. 1999 issue of the Journal of Pediatrics.

Basically, by taking blood via finger pricks at different times of the day, these researchers were able to more accurately tell the level of hormonal control of their CAH patients, and adjust treatment accordingly. As has been discussed on this MB many times before, hormone levels fluctuate during the day (with the biggest surge in the early am hours), and a reading based on one blood draw may not necessarily tell an accurate story. This article confirms that by saying, "...afternooon and evening 17ohp levels were often normal when morning 17ohp levels were...elevated. Thus 17ohp measurements obtained later in the day...during routine office visits will result in the false impression that these patients are adequately treated."

The paper reports that these scientists took patient blood samples (before HC doses) at 7am, 5 pm, and 9 pm over a period of time. They found that patients who were well controlled ( 17 ohp levels always below 10 nmol/L) showed stable levels throughout the day. Patients who were mildly undertreated (OHP levels between 10-50 mmol/L) showed elevated ohp levels in the morning or midday, but normal levels in the evening. For those patients, the evening dose of HC was administered later in the evening or increased. Patients with the greatest degree of undertreatment (OHP levels between 50-100 nmol/L or above 100 nmol/L), always showed elevated levels in the morning, and often in the afternoon and evening, as well. For those patients, the morning dose of HC was increased. Dose adjustments were continued until blood drawn at ALL times of the day showed adequate suppression. (Note: please note that these OHP levels are in nmol/L and not ng/dl which most of us are used to.)

It is well documented that hormonal surges follow a circadian pattern, and are greatest in the early morning hours. As part of the bigger am/pm dose debate, though, I thought that this article was interesting because it suggests that the timing of the larger dose might also be related to the DEGREE of undertreatment.

P. S. My suggesting that Lisa speak to her ped. endo about moving the bigger dose to the am for her child, was not related to this issue of hormonal control. By suggesting that the large evening dose of  of HC might be making her daughter hyper, because of increased blood sugar levels, I was speaking only to the "sleep" issue (which was the one that had been brought up).