ACTH Test

Dear Dr. Mark,

I was switched to Synthroid and a bit of Cytomel in lieu of 3 gr. of Armour.  Seems so far to be working. My 24 hr. cortisol urine was right in range.  But, she is wanting an ACTH test done at a hospital here.  What is this test and is it dangerous for one that has had a heart attack and an A-Fib attack?  Side effects?  I am due a cortisone shot in the knee three days later from my Orthopedic doctor.  Will this ACTH test hinder the cortisone test?  Thanks for your help.

[Mark Lupo, M.D.]

ACTH stimulation is a common test to exclude adrenal insufficiency -- it is very safe in most cases even in patients with heart disease (would usually wait 6 months after a heart attack to be safe, but even this is not likely necessary).  The test involves placing an IV then drawing blood, then giving a dose of ACTH and drawing blood at 30m, 60m and possibly 90min for cortisol.

The test would be skewed by the cortisone injection - either do before the injection or wait 3-4 weeks after the injection.  The ACTH test, however, will not hinder the therapeutic effect of the cortisone shot.

[MinnieM]

Thanks so much for your reply.  I had a gut feeling about the cortisone shot in knee first and the ACTH test as I was contemplating getting a knee shot first as this endo wants me to have the ACTH test at a "not so well known hospital" on the edge of this very large city with a great Medical center and this so called hospital has no valet parking and one must park in a garage and walk across the street and down a ramp, etc. etc. Now, with a bad knee that needs periodic cortisone shots till surgery (cardio has advised the OS that I cannot have knee surgery for another 4 months as I am on Plavix and he is adamant that I not be off plavix till then), I need convenience and safety wherever I go with this bad knee.  I called this "off beat hospital" and asked them the same thing I asked you.  I knew they were wrong stating everything would be OK if I had the cortisone first. Gads.

Friday, I called the Endo office (Endo on vaction for another week)and asked why I cannot go to one of the two large hospitals that are highly rated with valet parking and handicap friendly.  Secretary told me that they only use this "hospital" as it is the only one that knows how to do an ACTH test correctly. Duh!  I am toying with the idea of finding another Endocrinologist who will use another hospital.

Thanks again and thanks Cindy and Phil for Dr. Mark.  Happy New year To All.

~~~~~~~~~~~~~~~~~~~~~~~Live and Learn~~~~~~~~~~~~~~~~

[HashiMan]

I was just wondering if you mind me asking what your symptoms have been that led your Dr. to believe it might be adrenal?
I know you're a thyroid patient too, so was just wondering how the adrenal was in relation to the thyroid. Has your thyroid med seemed to be affected by the adrenal problem?
I've gone through this same senario, so just trying to get all the imput I can from patients with similar problem.
When I got on thyroid med, I developed worsening symptoms in certain areas. I had already had a saliva cortisol test (8:00AM & 12:00PM) previous to starting thyroid med and the levels were lowest end of normal but not quite borderline. After getting on thyroid med and having certain symptoms worsen, I rechecked cortisol and it had gone down to clinically low!
Example: One done after 6 months on med: 8:00AM-"0.23"(range 0.27 to 2.06 mcg/dl)  12:00PM-"<0.03"(range 0.03 to 0.50 mcg/dl)

Every few months I retested and thankfully, my cortisol levels went back up, but never above low-normal and if my med is increased, I always go through a drop in levels. I get more fatigue & joint pain at these times and feel I've never been at 100% because of this cortisol problem. Just in past months I've done better with symptoms and hope the trend continues but several Dr.s I've spoken to, state there is "no treatment" for this type of SUB-clinical adrenal problem. I'm not sure I disagree after researching about adverse effects of cortisol steroid replacement. I feel "adrenal glandulars" might be a much safer treatment but Dr.s won't prescribe such "naturals". Synthetics and steroids have completely replaced all natural supplements. Naturals were all they used in the early days of thyroid, adrenal etc... treatments, so makes one wonder why it is being turned against in such an extreme way? Just talked to a lady TODAY, responding to a newsletter I publish and she said Dr.s told her the same thing about her hypo-cortisolism being untreatable, due to being sub-clinical and not full-blown adrenal insufficiency (adrenal fatigue/exhaustion).

[MinnieM]

Hi there.  I am not an expert in this area.  It was this new Endo I saw due to the recent discovery of two nodules on the thyroid which were not there via ultrasound in 2001. I also informned her that a Serum Ferritin test that "I asked for" at my GP's office in September came back low (16) and a subsequent test 3 weeks later came back a 12.  I asked for this test at my GP's because I felt like *^&$%^%$&^%(*!   My Cardio doc ordered iron serum tests and they were normal.  This new Endo said the first thing to go low is the Ferritin as a front runner on its way for Iron Deficiency Anemia.  Then CBC and Iron tests start to show the anemia also.  I feel the nodules and low Ferritin is the reason she is ordering the Cortisol/Adrenal tests.  The 24 hour cortisol test (urine) was normal though.  My Cardio has put a damper on any tests that may cause me to bleed as I am on Plavix but the female doctors I am seeing are not happy about this as they want to do a Colonoscopy and EGD.  Right now, there are too many Chiefs and not enough Indians in my care and I literally do not know which end is up.  Stay tuned....and Good Luck to you.

[ancientmariner]

I've heard about a book called "Safe Uses of Cortisol" by a Dr. William K. Jeffries - haven't read it myself, but from what I've heard, he says that physiological (not pharmacological) doses of cortisol are safe. Dr. Barry Durrant-Peatfield advocates the use of cortisol, as well, in his book "The Great Thyroid Scandal", which I have read, and highly recommend.

[HashiMan]

I've not read the book but have read several articles that were summations of the Jeffries book.  I feel it is true that physiological cortisol doses to supplement and not replace, should be safe, since many Dr.s report success.
I consulted with an Osteopath Dr., Sherri Tenpenny, a reputable physician, who heads several medical boards and she told me she has had success for years treating thyroid patients with co-existing sub-clinical adrenal insufficiency, with low-dose "Cortef".
When I went to my Endo about it, he disagreed but I lean toward her evaluation. She also feels TSH is not the test for evaluating thyroid treatment but the "free" levels of T-3/T-4.
If you put in a search using her name, you'll see she's very involved in medical research and somehow connected with the Barnes Insitute.
I't amazing how someone this renouned has opinions and treatment recommendations that go completely against what most other Dr.s recommend. This isn't "patients VS Dr.s", it is "Dr.s VS Dr.s", that's why those who get mad when we express those controversial opinions, should realize, there are legitimate, reputable Medicals backing both sides!!
Thanks for the correspondence about this, I like seeing these things brought out.

[ancientmariner]

My doctor has me taking Isocort, which is an OTC adrenal supplement containing adrenal cortex (not the whole gland) and echinacea and other herbs. According to the doctor, each pellet contains 2.5 mg of cortisol - the bottle doesn't say that, but I think if they said how much, they'd have to be prescription. I take 2 pellets 3X a day, equivalent to 15mg of cortisol. It helps immensely.

[MaryRoe]

Mariner did your doctor recommend this OTC cortisol because you were low in this.  Did you have blood tests?  I am wanting to run out and get this but need more information.  Thanks

[ancientmariner]

Yes, I had the 24-hour saliva testing from Diagnos-Techs done, and it showed low cortisol at each of the 4 testing times. So my doc wanted me to supplement, and suggested I try the Isocort first and if I needed something stronger we could then try prescription med.