Supporting the Adrenals All Rights Reserved. 1

Size: px

Start display at page:

Hilary Tucker
5 years ago
Views:

2 Disclosure Baylor Rice, RPh, FIACP, is the pharmacist and owner of South River Compounding Pharmacy & Wellness Center. Conflict of interest was resolved through peer review of slide content. Professional Education Services Group staff have no financial interest or relationships to disclose All Rights Reserved. 2

3 Disclosure This continuing education activity is managed and accredited by Professional Education Services Group. Neither PESG nor any accrediting organization supports or endorses any product or service mentioned in this activity All Rights Reserved. 3

5 Learning Objectives At the conclusion of this activity, the participant will be able to: Describe the underlying physiology of Adrenal Fatigue. Discuss techniques for relieving stress. Explain various compounding treatment options and nutritional supplements for the person suffering from Adrenal Fatigue All Rights Reserved. 5

vitality and health optimization Review the definition and role of neurotransmitters Discuss strategies for

6 Educational objectives Review adrenal anatomy, physiology and HPA axis regulation Understand assessment of adrenal function Learn to identify the phases of adrenal dysfunction Obtain treatment protocols for adrenal vitality and health optimization Review the definition and role of neurotransmitters Discuss strategies for treating the symptoms of neurotransmitter imbalances without prescription medications All Rights Reserved. 6

7 We need stress (but too much or too little is counter-productive) Stress and stressors are essential ingredients of an effective, efficient, productive and satisfying life R.M. Yerkes and J.D. Dodson All Rights Reserved. 7

Over-exposure to stress hormones accounts for 75%-90% of all primary care visits in the U.S.

to the 6 leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis,

abuse (National Institute for Occupational Safety and Health) American Institute of Stress,

8 Over-exposure to stress hormones accounts for 75%-90% of all primary care visits in the U.S. Almost all illness is stress-related Caused by stress Aggravated by stress Causes stress Linked to the 6 leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis, and suicide #1 reason why people Eat poorly Quit healthy lifestyle programs Practice substance abuse (National Institute for Occupational Safety and Health) American Institute of Stress, America s #1 health problem All Rights Reserved. 8

9 Stress proneness The main stress to the majority of us - most of the time - is not due to external stimuli but to the pressure of our own suppressed emotions these suppressed emotions become the primary stressor so that even in a calm external environment we are still subject to chronic internal stress David Hawkins MD Ph.D Letting Go p All Rights Reserved. 9

10 It s not what we have to deal with, it s how we deal with it that makes all the difference let s differentiate between stress and stressor VERY empowering to distinguish between being a victim to all that is happening outside us, versus being in charge and deciding how to manage one s internal state regardless of stressors All Rights Reserved. 10

response Facilitates Negative Feedback Loop 1.*Sympathetic Nervous System Adrenal Glands 2.

12 A healthy stress response is short lived Perceived Stressor 2 Hypothalamus 1 Sympathetic ALARM Response (SNS*) (norepinephrine noradrenalin ) Pituitary Gland ACTH Resolution turns off stress response Facilitates Negative Feedback Loop 1.*Sympathetic Nervous System Adrenal Glands 2. Adrenocorticotrophin hormone 3. Corticotrophin releasing hormone Kidneys 3 Cortisol 3 Resolution All Rights Reserved. 12

Continual exposure to stressors is a biochemical event that

diet toxic burden health status occupation lifestyle social

13 Continual exposure to stressors is a biochemical event that excites the sympathetic nervous system, putting the entire body on the alert. An individual s stressortolerance varies based on: genetics diet toxic burden health status occupation lifestyle social skills community network family and friends human experience Kyrou I Ann N Y Acad Sci All Rights Reserved. 13

14 When we exceed our personal threshold of stressor-tolerance we break down. Everyone s breakdown is unique Digestive upset Breathing difficulties Cardiovascular Physical problems Emotional & social challenges Mental impairment Sleep disorders All Rights Reserved. 14

15 Americans are over working "Workers in the United States are putting in more hours than anyone else in the industrialized world. ~ Lawrence Jeff Johnson the chief labor market economist CNN. Study: U.S. employees put in most hours. Available at: Accessibility verified October 3, All Rights Reserved. 15

And yet we are less efficient and less productive than many industrialized nations Japan, Belgium

17 Pathological symptoms of binary brain imbalance HPA Overresponsiveness Excess SNS Hyper-aroused, hyper-vigilant anxious, worried Elevated cortisol Belly fat or weight loss Decreased appetite Decreased libido Insomnia Hypertension, tachycardia Pain and inflammation HPA Underresponsiveness Excess PSN Lethargy and fatigue Apathy, low motivation Low cortisol Weight gain Increased appetite Hypersomnia excessive sleep Depressed immune activity Autoimmune disorders Chronic pain All Rights Reserved. 17

The End of Stress as We Know It. 2002, p.

18 Conditions linked with over- & under-production of cortisol Over-production (excitatory) Cushing s syndrome Depression & OCD Diabetes Anorexia nervosa Myocardial ischemia, arrhythmia Hypertension Lipid disorders Childhood abuse Hyperthyroidism Depression B. McEwen. The End of Stress as We Know It. 2002, p.64 Under-production (inhibitory)) Addison s disease Seasonal depression CFIDS and Fibromyalgia Myocardial infarction Allergies/Asthma Rheumatoid arthritis Post traumatic Stress Syndrome Hypothyroidism Atypical depression Chronic pain All Rights Reserved. 18

19 Common Adrenal Symptoms Fatigue/lack of energy Energy crashes mid-afternoon Craving salty food Craving sugars Exhausting easily Decreased sex drive Sensitive to changes in weather Dark circles under eyes Wounds healing slowly Body tender/sensitive to touch Feel puffy/swollen all over Mind racing at bedtime All Rights Reserved. 19

20 Role of Cortisol Cortisol has two modes of operation: Proactive" mode - It promotes coordination of circadian events, such as the sleep/wake cycle and food intake and is involved in processes underlying selective attention, integration of sensory information, and response selection. Re-active" mode - It facilitates our ability to cope with, adapt to, and recover from stress; cortisol promotes learning and memory processes. Lopen-Duran NL, et al. Hypothalamic pituitary adrenal axis functioning in reactive and proactive aggression in children. J Abnorm Child Psychol. 2009; 37: Koolhaas JM, et al. Coping styles in animals: current status in behavior and stress physiology. Neurosci Biobehav Rev. 1999; 23: All Rights Reserved. 20

21 Cortisol is needed for life With all the negative side-effects, doctors became wary of cortisol use. But cortisol is essential for life. It is a normal hormone secreted by the body. In physiological doses, when cortisol levels are low, it can greatly improve quality of life. It gave me a life again 48 yo CFS patient All Rights Reserved. 21

Role of DHEA Throughout our reproductive years DHEA serves as a prohormone for androgens and estrogens All the enzymes required to transform DHEA into androgens and estrogens are expressed in a cell

23 Role of DHEA Throughout our reproductive years DHEA serves as a prohormone for androgens and estrogens All the enzymes required to transform DHEA into androgens and estrogens are expressed in a cell specific manner in a large series of peripheral target tissues like the breast, prostate and skin This permits the local tissue to make decisions and control the level of sex steroids according to their local needs All Rights Reserved. 23

Role of DHEA DHEA has a clear role in sexual development For many years scientists thought that DHEA production in adults functioned only as a precursor reservoir for testosterone and estrogens.

24 Role of DHEA DHEA has a clear role in sexual development For many years scientists thought that DHEA production in adults functioned only as a precursor reservoir for testosterone and estrogens. However, it is now well understood that in adulthood, DHEA can be secreted in response to ACTH stimulation just as cortisol is. Therefore, it also plays a role in the stress response All Rights Reserved. 24

Role of DHEA: stress management DHEA has been shown to elevate

All very important qualities to have during stress.

more on mood than on physical preparedness.

25 Role of DHEA: stress management DHEA has been shown to elevate mood, calm emotions and increase alertness. All very important qualities to have during stress. It appears that the actions of DHEA during stress may in fact be more on mood than on physical preparedness. DHEA helps our mind cope more evenly with stress and helps improve memory. Xie, L et al All Rights Reserved. 25

26 DHEA and health Roth et al. showed that the lifespan of a person and the serum concentrations of DHEA are positively related. There are also reports suggesting DHEA has Anti-atherosclerotic Anti-diabetic Anti-inflammatory Anti-osteoporotic Anti-senility functions All Rights Reserved. 26

27 Testing adrenal hormones Before beginning any treatment protocol on the adrenal glands a complete history should be taken and testing should be done. There are 3 fluids which can be tested: Saliva Serum Urine All Rights Reserved. 27

Adrenal function testing Diurnal cortisol = 4 cortisols (AM,

30 Adrenal Treatment Guidelines Phase 0 Multivitamin/Multi mineral Omega 3 EFA s Consider Vitamin D3, iodine, and probiotics Phase 1 Phosphorylated serine 100mg TID or when cortisol is elevated Vitamins B5 (500mg), Vit. C (1000mg) TID, B 6 (100mg) BID, E (800iu) QD Melatonin 3-5mg HS if cortisol levels elevated HS Lifestyle modifications: deep breathing, stress management, exercise, optimal diet, etc. Phase 2 Vitamins B5 (500mg), Vit. C (1000mg) TID, B 6 (100mg) BID, E (800iu) QD Adrenal glandular and/or herbal adaptogens in AM and Noon Lifestyle modifications: deep breathing, stress management, exercise, optimal diet, etc. Phase 3 Vitamins B5 (500mg), Vit. C (1000mg) TID, B 6 (100mg) BID, E (800iu) QD Adrenal glandular and/or herbal adaptogens in AM and noon Hydrocortisone supplementation 5-10mg in AM and 5-10mg at noon Lifestyle modifications: deep breathing, stress management, exercise, optimal diet, etc All Rights Reserved. 30

31 Treatment Mind-Body-Spirit List top ten stressors Identify and recognize the significant sources of internalized stress in one s life. Unravel underlying fatalistic attitudes and internalized beliefs which may be unconsciously promoting helplessness and faulty self-talk like there s nothing I can do about it Cultivates positive healing potential Opens the door to planning a coping plan which is pro active All Rights Reserved. 31

Balanced Cortisol Secretion (Phase 0) A balanced adrenal panel has the following properties Samples earlier in the day are always higher than samples later in the day.

32 Balanced Cortisol Secretion (Phase 0) A balanced adrenal panel has the following properties Samples earlier in the day are always higher than samples later in the day. Most people s samples peak at 8am (30 min after waking) and decline rapidly over the next few hours and then decline more slowly across the day to reach the lowest point around midnight. Salivary Cortisol 0 Hour of Sample Collection 8am 18.9nmol/L (14-32) 12noon 6.7nmol/L (4-13) 5pm 5.5nmol/L (3-7) 9pm 3.3nmol/L (1-4) All Rights Reserved. 32

Newborns Newborns do not have a diurnal cortisol pattern (any parent could tell you that) It develops during the first 12-20 weeks after birth. They also don t make DHEA. Iwata O, et al.

33 Newborns Newborns do not have a diurnal cortisol pattern (any parent could tell you that) It develops during the first weeks after birth. They also don t make DHEA. Iwata O, et al. Diurnal cortisol changes in newborn infants suggesting entrainment of peripheral circadian clock in utero and at birth. J Clin Endocrinol Metab. 2012; Nov 12: Epub. Hui XG, et al. Development of the human adrenal zona reticularis: morphometric and immunohistochemical studies from birth to adolescence. Endocrinol. 2009; 203: All Rights Reserved. 33

Teenagers A teenagers diurnal rhythm shifts by 1-2 hours, with a cortisol awakening response (CAR) at between 9 and 10 am. This may be why it is so hard to get them up in the morning.

34 Teenagers A teenagers diurnal rhythm shifts by 1-2 hours, with a cortisol awakening response (CAR) at between 9 and 10 am. This may be why it is so hard to get them up in the morning. Matchock RL, et al. Dirunal and seasonal cortisol, testosterone and DHEA rhythms in boys and girls during puberty. Chronobiol Int. 2007; 24: Oskis A, et al. Differences between diurnal patterns of salivary cortisol and dehydroepiandrosterone in healthy female adolescents. Stress. 2012; 15: All Rights Reserved. 34

HPA axis dysregulation: cortisol elevations or zig zag pattern In this situation the cells that secrete CRH become less sensitive to cortisol later in the day rather than early in the morning.

35 HPA axis dysregulation: cortisol elevations or zig zag pattern In this situation the cells that secrete CRH become less sensitive to cortisol later in the day rather than early in the morning. It is seen more often in depressed individuals. Depressed individuals exhibit increased cortisol secretion in the afternoon. Elevated evening cortisol levels are often seen in people with financial difficulties and unemployed individuals. It can lead to a change in the sleep wake cycle. People will have difficulty settling down and falling asleep at night and then have trouble waking up in the morning All Rights Reserved. 35

36 Flatliner cortisol slopes (AKA: hypoadrenia) This is referred to as A Little bit of Addison s. These slopes have comparatively the least variation in morning to night cortisol levels. Flatter slopes are also associated with exposure to stressful social experiences, chronic fatigue, fibromyalgia, and rheumatoid arthritis. (Adam et al. 2001) Very low circulating cortisol is associated with debilitating fatigue. (Cleare et al. 2003) All Rights Reserved. 36

37 Prescription Tablets are available for oral administration in three strengths; each tablet contains either 5 mg, 10 mg, or 20 mg of cortisol. Inactive ingredients: calcium stearate, corn starch, lactose, mineral oil, sorbic acid, sucrose All Rights Reserved. 37

Potency comparisons 0.5 mg of dexamethasone = 15 mg cortisol (40x stronger) In a dexamethasone suppression test usually 1 mg of dex is given orally (about 30 mg cortisol).

39 Potency comparisons 0.5 mg of dexamethasone = 15 mg cortisol (40x stronger) In a dexamethasone suppression test usually 1 mg of dex is given orally (about 30 mg cortisol). 5 mg prednisone = 20 mg cortisol (4x stronger) A normal starting dose of prednisone is between 5-60 mg/day. Multiple sclerosis treatment starts at 200 mg/day and tapers to 80 mg/day. Cortisol (hydrocortisone) Prednisone Dexamethasone 20mg 5mg 0.75mg All Rights Reserved. 39

40 Metabolism of cortisol Short half-life: 8 to 12 hours 1. Cortisone 2. Cortisol Cortisol is metabolized in most tissues, but primarily in the liver to biologically inactive compounds. The half-life of cortisol may be prolonged in patients with hypothyroidism. Inactive metabolites are excreted by the kidneys. Negligible amounts are excreted in bile All Rights Reserved. 40

41 Monitoring levels Monitor patients on cortisol via four salivary cortisol levels collected throughout the day one month after starting. Patients can be instructed to dose as usual the day of testing. Discontinue supplementation for 4-5 days prior to testing to assess endogenous levels. Salivary Cortisol 0 Hour of Sample Collection All Rights Reserved. 41

42 DHEA supplementation does NOT increase cortisol levels! DHEA will not increase cortisol levels, it will not strengthen the area of the adrenal glands that makes cortisol (zona fasciculata) and it will not exert a negative feedback on the HP axis All Rights Reserved. 42

43 Dosing of DHEA The amount of DHEA needed to bring a male with Addison s disease into normal physiological range is mg (Hunt et al. 2000). If you are following physiological (not replacement) doses you would most likely not exceed: Males mg/day Females 5-15 mg/day Starting place: 10 mg for males and 5 mg for females. Hunt PJ, et al. Improvement in mood and fatigue after dehydroepiandrosterone replacement in Addison's disease in a randomized, double blind trial. J Clin Endocrinol Metab. 2000; 85: All Rights Reserved. 43

44 Dosing of DHEA 25 mg of DHEA per day given to a man over the age of 41 brings DHEA, androstenedione and estrogen levels into a range seen in 20 year olds. (Yamada et al. 2006) All Rights Reserved. 44

45 DHEA dosing It can be dosed: Orally Sublingually Topically All work well Pearl: When DHEA is put into a cream with other hormones such as progesterone and BiEst, DHEA will out compete the receptors and and interfere with absorption of other hormones All Rights Reserved. 45

Therapeutic Cohort Results

Patient: SAMPLE PATIENT DOB: Sex: MRN: Menopause Plus - Salivary Profile Therapeutic Cohort Results Hormone Average Result QUINTILE DISTRIBUTION 1st 2nd 3rd 4th 5th Therapeutic Range* Estradiol (E2) 8.7