Question: I am trying to taper my replacement dose of hydrocortisone, but I am having difficulty tapering due to a rapid heartbeat which happens when standing and during stress. My AM cortisol is 9nmol/L. Is this normal during tapering? Should I increase my dose?

Answer: Your very low cortisol levels indicate that your hypothalamic-pituitary-adrenal (HPA) axis is still quite suppressed. You do not mention the reason for this suppression and when the excess cortisol (either from therapy with high doses of glucocorticoids for a medical inflammatory disease, or from a pituitary tumor secreting too much ACTH -Cushing’s disease- or from an adrenal tumour secreting too much cortisol) was removed. It can take on average one year and sometimes more in severe cases to progressively recover normal function of the pituitary and remaining adrenal. Depending on the severity of the manifestations of the previous cortisol excess, it may take a few months before replacement of hydrocortisone can be decreased from 30-40 mg daily in 2-3 split doses during the day down to only normal levels of 20 mg in the morning only. That will allow more complete recuperation of the pituitary and remaining adrenal function. Trying to decrease the dose of hydrocortisone too rapidly often produces signs of withdrawal including intense fatigue, lack of appetite, nausea, muscle and joint pain; it is also possible that blood pressure will be relatively low and this may cause palpitations when standing up. On the other hand, if a patient continues excess hydrocortisone replacement, he may never recover normal function of his pituitary and adrenal. Careful, progressive tapering over several months is very likely to be met with success unless the pituitary gland was removed too extensively at the time of surgery. Never forget to wear your medical bracelet indicating the requirement of stress doses of cortisone in case of acute illness.

By Dr. Andre Lacroix MD (Summer, 2012)