Thanks Carol. I’m just getting ready to go away for a couple of weeks (my mother-in-law died while staying with us before Christmas) so we are leaving tomorrow to go and sort out her things in another state, so this will be pretty sketchy and brief.

 

I think that there are two factors not just quantity of doses but timing of the doses.

 

In order to understand what we are doing wrong in terms of Cortisol replacement doses we need to know what happens in the normal functioning body. From these graphs below we can see that cortisol in the normal child (and the process is very similar in teens and adults), starts to drop around the 4pm and starts to rise again around 3-4am.

 

SORRY THE GRAPHS DID NOT COPY and I’m a bit pressed for time to go find them again.

 

Many of our medication doses have been given for many years at times which defy this inherent circadian rhythm. In fact late evening doses are often the norm. So instead of having a low level of cortisol in the blood at 11pm/midnight, as is the norm, we often have a very high level due to late doses.

 

It is often said that excess levels of glucocorticoids (this also includes high blood levels at the wrong times) also known as Adrenal catabolic syndrome produces too much wear and tear and not enough rest and repair on body cells and tissues.

 

Human growth hormone (hGH) secretion follows a circadian rhythm, with the largest pulse secreted about an hour after the onset of night-time sleep (around midnight for most adults). This in the healthy person occurs at a time when the cortisol level is at its low ebb. What do we do to ourselves when we tangle these up and have the late dose of cortisol before bed. This ideally is when the growth hormone should be at its highest when the cortisol level, is at its lowest.

There is no doubt that the ‘replacement doses’ do not always coincide with need, so there is a continual oversuppression and undersuppression happening. As LauraK has said: “ A fairly typical dosing schedule of equal doses of Cortef is given at 7am, 3pm, and 11pm”. In this regime “there are big areas of under-replacement and big areas of over-replacement. This schedule results in a period of under-replacement during the early morning hours and the early afternoon hours. It guarantees a period of over-replacement in the early sleep hours, during the time when growth hormone is trying to peak”. What damage does this do over the long term?

So in terms of dosing I think that timing is as important. In regard to under or oversuppression, I prefer (as an adult) to lean on the side of undersuppression, so long as I feel reasonably well. As far as a child goes, I’d probably rather not say.