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Editorials

Glucocorticoid replacement

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4843 (Published 30 July 2014) Cite this as: BMJ 2014;349:g4843

Re: Glucocorticoid replacement

Understanding glucocorticoid replacement is essential to reduce mortality and morbidity for patients with adrenal disorders. I agree with the sentiment that we should mimic the circadian rhythm but once daily treatment with any of the medications suggested will not mimic the rhythm. Studies on cortisol undertaken on individuals with normal production show that there is always measurable cortisol in the blood. The levels do drop late evening for several hours to a lower amount but not to zero. The pharmacology of prednisolone will not achieve this as duration in the circulation is no more than 8 hours which even if you gave it at 2am would mean that all the drug was out of the circulation by 10am and even then the medication would have peaked at about 4-5am leaving the individual deficient in glucocorticoid for the whole of the day and evening at a crucial point when cortisol should be around.

The side effects of prednisolone are quite dramatic particularly in paediatrics. We know from a few young patients who have taken prednisolone they have become suicidal and once back on hydrocortisone those tendencies and thoughts have disappeared.

The only way that side effects can be minimised is to get therapy as close as is possible to the circadian rhythm. This can be achieved with three or four times daily hydrocortisone therapy or alternatively pump therapy.

Competing interests: No competing interests

07 August 2014
Peter C Hindmarsh
Professor Paediatric Endocrinology
University College London
Institute of Child Health, 30 Guilford Street, London WC1N 1EH