5. Adrenal Insufficiency

This might be more properly described as low adrenal reserve. Since hypothyroidism adversely affects every cell, every tissue, and every gland in the body it is clear that the endocrine system as a whole will be also similarly affected. The adrenals will be subject firstly to lowered efficiency resulting from a lowered vitality primary to hypothyroidism, and secondarily, to reduced ACTH stimulation from the pituitary. As a result, in general, patients with a protracted and/or severe hypothyroid state will have some degree of adrenal insufficiency. A significant level of this will be suspected in these situations:

a. Longstanding and severe hypothyroidism.

b. Episodes of extreme exhaustion, or collapse.

c. Bad response to minor illness.

d. Multiple allergies.

e. Digestive problems – alternate diarrhea and constipation

f. Flatulence

g. Weight loss

h. Increasing arthralgia (fibromyalgia) and morning stiffness.

i. Pallor, yellow pigmentation (due to poorly metabolized carotene)

j. Fainting, dizziness

These patients often present with dark rings under their eyes, looking quite ill. Blood pressure is low, with a positive Raglan’s sign. (Pressure fails to rise on standing). These symptoms and signs, it will be appreciated, are those of the early phases of Addison’s Disease.

A single estimation of blood Cortisol is usually unhelpful, but De-hydroepiandrosterone sulphate (DHEA), the main hormone output from the adrenals, will be found to be low. Depressed levels in the endocrine system as a whole are likely to be found. The low adrenal reserve means patients are more or less well, until challenged by the stress of illness or life events--even the thyroid replacement therapy itself initially. And this partial failure will affect adversely T4-T3 conversion and the integrity of the thyroid receptors.

It is essential to manage this insufficiency where present, or where suspected. Remarkably, patients with symptoms, signs and blood pathology of low thyroid, may improve completely on management and correction of the adrenal problems alone; as conversion and receptor efficiency improves, the thyroid hormone circulating - partly unused - is brought into play.

Adrenal insufficiency is dealt with by the provision of the two hormones most likely to be lacking; Cortisonehydrocortisone, and DHEA. (as pointed out above, low DHEA may be used to infer low cortisone output). The treatment therefore, is the exhibition of, ideally, Hydrocortisone. This should be given in divided doses initially of 5mg qds; after a week, 10 mg qds may be used. This remains a physiological dose, not challenging or suppressing the adrenal function, but supplementing it. In these doses all of the usual anxieties associated with

cortisone do not apply, since restoration of normality is being aimed at.

This may need to be explained to patients long subject to media-induced fears of the horrors of corticosteroids (Their physicians may share these anxieties, unnecessarily). Dr McCormack Jeffries’ papers on the subject are most worthy of study. DHEA has reached prominence in recent times as a hormone of multiple, and magic properties. Certain it is that the adrenals secrete more DHEA than anything else, and the amount is inversely proportional to age. It is metabolized to oestrogen and/or testosterone, but also has been shown to play a role in reducing obesity; in reducing atherosclerosis and cholesterol; it inhibits the glucose -6-dehydrogenase enzyme in cancer; it improves immune response, and, possibly, acts as a neural facilitator. In physiological doses, there seems to be no problem in its long-term use. If levels are demonstrably low, it is reasonable to provide replacement therapy.

Treatment Protocol

1. General consideration. Correction of Nutritional deficiencies, and elimination of environmental challenges and toxins, has been noted above.

2. Simple, early hypothyroidism. Readily available tablets of Levothyroxine 50mcg may be used. Initial dose is low (in the elderly as low as 25mcg daily) and will usually start at 50mcg daily. This may be increased 25mcg daily every two or three weeks. The ceiling is reached at the judgement of the physician with feedback from the patient. It is unusual to go higher than 300mcg.

3. Moderate hypothyroidism. If the synthetic products are to be used, many patients will benefit if, when a dose of 100mcg or more levothyroxine is used, Tertroxin (T3) is added. 10mcg for each 100mcg of T4 is to be preferred. The dose may be increased incrementally at the physician (and patient’s) discretion.

If natural thyroid is to be used, a start may be made with 1/2 grain (30 mg). (Commensurate with its 100 years of use by the medical profession, natural thyroid is still measured in grains). Dosage is increased by 1/2 gr. every two weeks; usually by six weeks the dose will level off. Improvement on any given dose continues for weeks and weeks, and the temptation, scenting victory, to increase the dose too soon, should be resisted. (One grain equivalent 60mg of natural thyroid is equivalent to 38mcg T4 and 9mcg T3). The definitive dose may remain unchanged for months or years, but the patients should be allowed to make small adjustments themselves, depending on activity, ambient temperature, for example.

4. Severe hypothyroidism. As indicated above, simple replacement is unlikely to be sufficient. Receptor block and adrenal insufficiency require adrenal support; preferably initiated a week before thyroid supplementation is started. A satisfactory protocol is to, start with 5mg hydrocortisone qds, and after a week, double the dose. Alternatively Prednisolone 2.5 mg (or the enteric-coated Deltacortril) may be used, doubling after a week. Clinical judgment, based on the patient’s condition being normal - perhaps after about three months - will enable the dose then to be halved, and then discontinued. It will be a matter of clinical judgment and preference to use T4 and T3, or natural thyroid.

Some patients already on levothyroxine (T4), but far from well, have to be considered separately. If the condition is really quite severe, and increasing thyroxine makes matters worse, it should be stopped for a short while and cortisone prescribed. The sudden improvement in thyroid uptake brought about by the cortisone may actually result in overdose symptoms if exogenous thyroid is continued. The treatment of choice is to restart thyroid hormone, using instead T3, after a 7 day interim period; 10 mcg for a few days, then 20 mcg and so on. After the improvement is seen to be full, and sustained, natural thyroid can be reintroduced. The general improvement may, secondarily, improve endogenous thyroid production, which can result in the overall exogenous dose being reduced.

As regards DHEA, its significance in the management of adrenal insufficiency is unsure, but where low levels have been found, it seems proper and logical to restore them to normality. In women 25mg daily, and men 50mg daily sometimes produces significant benefit. In this practice, its use has always been an advantage.

The management of hypothyroidism in children requires fine clinical judgement; but one quarter to one half of the adult dose seems to be a satisfactory starting point. Reliance on blood testing should be modified by clinical appraisal of the child and his parents’ observations. The diagnosis is often missed in children; and should be considered in any child often ill. The basal temperature test may prove a helpful pointer.

Thyroid insufficiency may have a number of different causes and its symptoms may masquerade as a number of different illnesses. It should always be considered in patients with prolonged ill health, and the diagnosis rely on history and examination. The reliance of the profession on the pathological tests in favor of thoughtful appraisal is to be deplored. The treatment is inexpensive and low tech, requiring a few simple guidelines and a listening approach by the physician. Rarely is consultant advice necessary; the family physician is well able to initiate and monitor the treatment even in quite severe cases. The rewards are invariable; with no fuss, and with delight, the patients always get better. This common condition is one of few where simple measures can transform patients’ lives.