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Q: I had a patient who was doing quite well with florinef, but now even the smallest doses cause her blood pressure to surge. Any thoughts?

Jennifer Sudarsky, MD FP

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A1: This patient may benefit from cortef which has lesser mineralocorticoid effects (and more glucocorticoid effects). I always look at adrenal hormone replacement as potentially temporary while I try to help support the adrenals with glandulars, licorice root, and adaptogens, as well as lifestyle measures to reduce stress (biofeedback, meditation, yoga, Tai Chi, etc).

Rick Linchitz MD (Linchitz Medical Wellness LinchitzWellness.com )

A2: She may have adrenal fatigue also check TSH FT4 FT3 and TPO. Consider switching corticosteroids.

Dr David Zeiger
Medical Director
healthWorks -Integrative Medical Center
1165 N Clark St
Suite 608
Chicago, IL 60610

A3: It would be helpful to know how rigorously you established your presumed diagnosis of adrenal-mineralocorticoid deficiency. Since your patient is not tolerating the florinef, this would be a great opportunity to stop it for a month or so to let the endogenous aldosterone recover. It is important to be on a very low salt diet for several days before and during the 24 hr urine collection to maximally stimulate aldosterone. Measure urine Na and K to verify that the patient adhered to the low salt diet. Aldosterone is another hormone that drops with aging. At the age of 55, my 24 hr aldo was 18 associated with a low urine Na of 77. Young people can get up to 28, so I thought I did well for my age, thus ruling out aldo deficiency as a cause of my relatively low BP of 100/60. Of course, include free cortisol and 17-OH corticosteroids with the 24 hr test to fully assess adrenal cortical function. Please don't do the test on a random Na diet because the results are too variable and nondiagnostic. Getting back to your patient, if adrenal fatigue is well-established, maybe it was due to some short-term stress that got resolved and then the florinef was no longer needed and would then cause high BP. Sometimes florinef is used carelessly for any cause of dehydration like gastroenteritis, so again it is not needed once the illness is gone. I hope this helps--Russell Laudon, MD.

A4: Could try aldosterone. Perhaps the patient could tolerate it better.
Key Pharmacy in Seattle area has it.
Rick

Richard S. Wilkinson, M.D.
Wilkinson Wellness Center
302 S 12th Ave
Yakima, WA 98902

A5: This is a very potent fluorinated cortisone, increasingly persistent in the body, with well known effects of increasing blood pressure. Calcium excretion is increased while sodium is retained.

You may be seeing aspects of chronic fluoride poisoning with adrenal depletion and calcium deficiency. As this worsens, the relative toxicity of fluoride (from any source including the drug) is increased. Look at uptake and accumulation of aluminum and other heavy metals. These are increased by fluoride and can account for blood pressure elevation too.

At Second Look we have a growing file of people who have developed chronic fluoride poisoning illness, many with increased metal toxicity aspects, after taking fluorinated pharmaceuticals like this. Even when minimal fluoride ion is released through metabolism of the drug, endocrine receptor poisoning can be far worse than we thought.

Aliss Terpstra CNP
Second Look - Fluoride Toxicity Research Collaborative http://www.SLweb.org

A6: Check out what it does to her aldosterone. May need to add OTC KCl in the form of "No Salt" to replenish potassium. Normally takes about a tsp/day. Sprinkling it on food won’t cut it.

A7: ugh, stop the florinef?
your question probably is what to do instead of the florinef, our question is what are we treating?

A8: The patient is taking Florinef for Polymyalgia Rheumatica. Thnx.

Jennifer Sudarsky, MD FP