Surgical Guidelines for Cortisol Deficiency

Surgical Guidelines for Cortisol Deficiency

*This information is for educational use only and is not to be used to treat or manage any condition*

During a surgical procedure, a cortisol deficient patient’s body will require an increase in steroid dosing to replace cortisol. Researchers[1] have reported that in non cortisol deficient patients, HPA axis function during and after surgical procedures causes plasma cortisol levels to increase significantly. In patients without the presence of adrenal insufficiency, cortisol production rates have been shown to increase to 75–150 mg/day after major surgery.

In cortisol deficient patients, the recommendations differ depending on the length and severity of the procedure being performed. Cortisol deficiency patients will always require additional glucocorticoid supplementation during surgical procedures, but there is no uniform standard accepted regimen for glucocorticoid replacement therapy.

It is the best clinical practice to treat the patient instead of following a textbook response. If a patient with cortisol deficiency is declining, the administration of more cortisol should be a first line treatment protocol.

Anytime a cortisol deficient person is going under anesthesia, intravenous cortisol replacement medication must be administered.

If you have cortisol deficiency, be sure you alert your surgical team that you are cortisol dependent before your procedure and have a clear plan for your steroid dosing pre, during and post procedure. Any surgical team who refuses to administer steroids should be reported to medical authorities. Adequate steroid coverage is essential to the well being of cortisol deficient patients.

suggested Surgical Cortisol replacement recommendations: [2]

*DISCLAIMER* There is no universally agreed upon standard dose or duration of exogenous steroids used to treat adrenal insufficiency. Clinicians must be observant of a patient’s vital signs, empirical evidence and quality of life. It is also imperative clinicians be aware of the symptoms of adrenal crisis, which can widely vary in patients. In the event these symptoms should arise, an immediate dose of glucocorticoids should be administered until patient stabilizes.

For Minor Surgery: Double or triple the usual daily dose of glucocorticoid until recovery. Intravenous hydrocortisone 25 mg or equivalent at start of procedure. Usual replacement dose after procedure.

For Dental Procedures: Under local anesthesia, double the daily dose of glucocorticoid on day of procedure.  Inject 100mg emergency cortisol injection if patient presents with adrenal crisis symptoms.

For Moderate Surgery: Intravenous hydrocortisone 75 mg/day on day of procedure (25 mg 8-hourly). Intravenous hydrocortisone 25 mg 8-hourly until recovery. Taper over next 1–2 days to usual replacement dose in uncomplicated cases.

For Major Surgery: Intravenous hydrocortisone 150 mg/day (50 mg 8-hourly) Taper over next 2–3 days only once clinical condition stabilizes.

For critical illness/intensive care/major trauma or life-threatening complications: 200 mg/day intravenous hydrocortisone (50 mg 6-hourly, or by continuous infusion)

This information was brought to you by the Adrenal Alternatives Foundation for educational use only and is not meant to provide medical care or advice.

Download a PDF of these surgical guidelines HERE

You can find more information on how to manage cortisol deficiency in our publication, Adrenal Insufficiency 101: A Patient’s Guide to Managing Adrenal Insufficiency 

Sign up for our member email list to get the latest updates.

We appreciate all contributions which allow us to further our mission, Education, Encouragement and Advocacy.

Donate to Adrenal Alternatives Foundation

Sources:


[1] JUNG, C. AND INDER, W. J.

Management of adrenal insufficiency during the stress of medical illness and surgery: Jung, C. and Inder, W. (2008). Management of adrenal insufficiency during the stress of medical illness and surgery. [online] Australasian Medical Publishing Company. Available at: https://www.mja.com.au/journal/2008/188/7/management-adrenal-insufficiency-during-stress-medical-illness-and-surgery .

[2] COLLARD MD, C. D., SAATEE, M.D, S., REIDY, M.D, A. B. AND LIU, M.D, M. M. Perioperative Steroid Management: Approaches Based on Current Evidence: Collard MD, C., Saatee, M.D, S., Reidy, M.D, A. and Liu, M.D, M. (2017). Perioperative Steroid Management: Approaches Based on Current Evidence. [online] Anesthesiology: Trusted Evidence Discovery in Practice. Available at: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2626031

Announcement! The Future of Cortisol Replacement is here.

Despite its revolutionary success rate, treating cortisol deficiency with the cortisol pumping method has long been a difficult process to obtain. Access to infusion pumps and supplies for non-diabetics and also finding healthcare providers willing to manage adrenal patients on this method are just a few issues that have caused massive barriers to achieve this treatment.

Adrenal Alternatives Foundation is changing that. We are proud to announce our latest resources to help patients safely and successfully start the cortisol pumping method. The following resources were established to aid adrenal patients in their journey to cortisol pumping.

As a collaborative publication containing medical studies, clinical research and documented patient empirical evidence, this book includes everything you need to know about the cortisol pumping method.

Cortisol 101 contains the following information:

Chapter 1: Introduction

What is Adrenal Insufficiency?

Important Terms

What is Cortisol Pumping?

Common Myths

Frequently Asked Questions

Chapter 2: Assessments

Testing

Pre-Pump Planning

Steroid Options

Hydrocortisone Injections

Post Pump Testing

Chapter 3: Starting the Cortisol Pumping Process

Finding a Pump Friendly Physician

Choosing a Pump System

Obtaining Insurance Approval

Chapter 4: Creating a Care Plan

Prescriptions & Items Needed

Choosing a Solu-Cortef Ratio

Setting Basal Rates

Updosing and Sick Rates

Sites and Absorption Factors

Chapter 5: Life with the Pump

Exercise

Showering

Traveling

Intimacy

Surgery Protocols

Chapter 6: Resources

Appeal Letter

Adrenal Alternatives Foundation

Sources

  • Cortisol Pumping Interactive Website. Adrenal Alternatives Foundation is proud to release the website, cortisolpump.org to provide an easily accessible, free resource on cortisol pumping available internationally. Click the link below to access the website.
  • Pumps for Purpose Program.   Adrenal Alternatives Foundation is proud to have partnered with the non profit, CR3 to create a program specific to adrenal disease patients to provide them with affordable pumps and supplies, with or without insurance coverage.
  • Physician Guidance. Our clinical team is proud to guide physicians on the necessary protocols that must be taken to safely and effectively create a care plan for adrenal patients seeking to manage their cortisol deficiency via the cortisol pumping method. Though we are not a replacement for medical care or advice, we are proud to help guide physicians on the proper lab testing and prescriptions needed to begin the cortisol pumping method.

If you need assistance on the cortisol pumping method, please fill out the contact form and we will have a team member contact you to schedule a free consult.

You can also download a One pager on the cortisol pump here.

This content has been brought to you by Adrenal Alternatives Foundation, a 5o1c3 non profit organization. We appreciate all contributions which allow us to further our mission, Education, Advocacy and Awareness for all adrenal disease. EIN: 83-3629121.

Donate to Adrenal Alternatives Foundation

What is the difference between blood, urine and saliva cortisol testing?

What is the difference between blood, urine and saliva cortisol testing?

*This information is to be used for educational purposes only and is not intended to provide medical care or advice*

There are three forms of cortisol in the body:

1.Free cortisol

2.Bound cortisol

3.Cortisol metabolites

Bound Cortisol– Cortisol which is attached to a specific protein (CBG) is known as a bound cortisol. Metabolized cortisol evaluates how much cortisol is being made in total and cleared through the liver.

Free Cortisol- Cortisol which is not attached to any protein known as free cortisol. Free cortisol reveals how much cortisol is free to bind to receptors and allows for assessment of the circadian rhythm.

Cortisol metabolites– Metabolites of cortisol gives insight into the relative activity of 11b-HSD types I and II, which controls the activation and inactivation (to cortisone) of cortisol.

Approximately 90% of cortisol is bound to cortisol-binding globulin (CBG), also known as transcortin, and albumin.  Transcortin: corticosteroid-binding globulin (CBG) or serpin A6, is a protein encoded by the SERPINA6 gene and is an alpha-globulin. Albumin: main protein in your blood and carries substances such as hormones, vitamins, and enzymes throughout the body.

5% of circulating cortisol is free (unbound). Only free cortisol can access the enzyme transporters in the liver, kidney, and other tissues that mediate metabolic and excretory clearance.

Cortisol-binding globulin (CBG) has a low capacity and high affinity for cortisol, whereas albumin has a high capacity and low affinity for binding cortisol. Variations in CBG and serum albumin due to renal or liver disease may have a major impact on free cortisol.

Standard Ranges for Cortisol:

A normal adult range for cortisol levels in urine is between 3.5 and 45 micrograms per 24 hours.

Reference ranges for salivary cortisol assay: <0.4–3.6 nmol/L at 2300 h & 4.7–32.0 nmol/L at 0700 h.

Standard 8 a.m. range for blood serum cortisol is between 6 and 23 micrograms per deciliter (mcg/dL)

Measuring both free and bound cortisol levels allows for insight into the rate of cortisol clearance/metabolism and clearance.

Urine and saliva cortisol testing are used to evaluate free cortisol levels. Morning saliva cortisol panels are done to measure the diurnal cortisol curve. Blood cortisol testing is used to evaluate total cortisol and also bound cortisol.

In patients with adrenal insufficiency, an evaluation of cortisol tested via blood, saliva and urine can all be beneficial in evaluating the efficacy of their cortisol replacement medication(s). Recommended protocols are a comparative assay of cortisol levels from urine, blood and saliva specimens. The patient’s quality of life, symptomatic complaints and also fatigue levels should also be used when evaluating a proper cortisol dosing regimen.

Sources:

Abraham, S. B., Rubino, D., Sinaii, N., Ramsey, S., & Nieman, L. K. (2013). Cortisol, obesity and the metabolic syndrome: A cross-sectional study of obese subjects and review of the literature. Obesity (Silver Spring), 21(1), 1-24. doi:10.1002/oby.20083

Dhillo WS, Kong WM, Le Roux CW, Alaghband-Zadeh J, Jones J, Carter G, Mendoza N, Meeran K and O’Shea D. Cortisol-binding globulin is important in the interpretation of dynamic tests of the hypothalamic-pituitary-adrenal axis. Euro J Endo. 2002;146

Hoshiro, M., Ohno, Y., Masaki, H., Iwase, H., & Aoki, N. (2006). Comprehensive Study of Urinary Cortisol Metabolites in Hyperthyroid and Hypothyroid Patients. Clinical Endocrinology, 64, 37-45. doi:10.1111/j.1365-2265.2005.02412.x

Taniyama, M., Honma, K., & Ban, Y. (1993). Urinary Cortisol Metabolites in the Assessment of peripheral Thyroid Hormone Action for Diagnosis of Resistance to Thyroid Hormone. Thyroid, 3, 229-233.

Tomlinson, J. W., Finney, J., Hughes, B. A., Hughes, S. V., & Stewart, P. M. (June 2008). Reducing Glucocorticoid Production Rate, Decreased 5alpha-Reductase Activity, and Adipose Tissue Insulin Sensitization After Weight Loss. Diabetes, 57, 1536-1543.

Bancos I, Erickson D, Bryant S, et al: Performance of free versus total cortisol following cosyntropin stimulation testing in an outpatient setting. Endocr Pract 2015 Dec;21(12):1353-1363 doi: 10.4158/EP15820

Petersen KE: ACTH in normal children and children with pituitary and adrenal diseases. I. Measurement in plasma by radioimmunoassay-basal values. Acta Paediatr Scand 1981;70:341-345

Hamrahian AH, Oseni TS, Arafah BM: Measurements of serum free cortisol in critically ill patients. N Engl J Med 2004;350;16:1629-1638

Ho JT, Al-Musalhi H, Chapman MJ, et al: Septic shock and sepsis: a comparison of total and free plasma cortisol levels. J Clin Endocrinol Metab 2006;91:105-114

le Roux CW, Chapman GA, Kong WM, et al: Free cortisol index is better than serum total cortisol in determining hypothalamic-pituitary-adrenal status in patients undergoing surgery. J Clin Endocrinol Metab 2003;88:2045-2048

Huang W, Kalhorn TF, Baillie M, et al: Determination of free and total cortisol in plasma and urine by liquid chromatography-tandem mass spectrometry. Ther Drug Monit 2007;29(2):215-224

Mayo Clinic Laboratories-  https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/65484

The Adrenal Alternatives Foundation is registered with the IRS as a 501(c)3 nonprofit organization.

EIN: 83-3629121.

Donate to Adrenal Alternatives Foundation

Celebrating Rare Disease Day 2020

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Rare Disease Day is an observance held on the last day of February to raise awareness for rare diseases and improve access to treatment and medical representation for individuals with rare diseases and their families.

For #RareDiseaseDay we invite you to join us with the
AI Butterfly Challenge, where we are raising our hands for adrenal disease awareness.

Our objective is to flood social media (pinterest, instagram, facebook and twitter) with our butterfly photos to spread awareness on ALL ADRENAL DISEASES!

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Rare Disease Day is February 29, 2020

To participate- Take a photo with your hands in the shape of a butterfly and upload to social media using the hashtags #RareDiseaseDay and #AIButterfly!

You can edit your photo with the template download here!!

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Or, if you’d like us to edit your awareness photo send your photo to adrenalalternatives@gmail.com

 

We hope you join us in raising awareness for all adrenal disease!

Exciting Announcement

As promised, we have an exciting announcement!

Adrenal Alternatives Foundation was created to help all adrenal disease patients find better quality of life. We are actively working to make sure treatment options are available to all adrenal insufficiency sufferers.

Access to the cortisol pump treatment is limited and this foundation is dedicated to helping people establish care and maintain pumps/supplies to achieve this life changing treatment.

In addition to our long term solutions for this issue, we are pleased to announce we have found a solution to eliminate the “black market” necessity for gaining access to pumps. The days of scouring eBay, craigslist and facebook for pumps and supplies are now over!

We are pleased to announce our affiliation with CR3, which is an organization dedicated to placing pumps and supplies in the lives of people who need them.

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Founders Winslow E. Dixon and Charles Ray III (pictured above) have created a program which combines the resources of both organizations in order to supply pumps to adrenal disease patients in a safe and legal manner.

To apply click the highlighted text.

You can also discover more information on cortisol pumping on our website.

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This is just one step into bettering the lives of future adrenal disease patients.

Change is coming for Adrenal Disease!

Stay tuned for updates!

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The Adrenal Alternatives Foundation is registered with the IRS as a 501(c)3 nonprofit organization. We are a patient empowerment organization that encourages, educates and advocates for sufferers of all adrenal diseases. EIN: 83-3629121