Patient referred to us for Short Synacthen test following, low baseline cortisol in the community, symptoms of fatigue, background history of neck pain on mild opioids, Paracetamol, codeine and Tramadol. Asthmatic on prn salbutamol inhalers. Before attending for Synacthen test patient asked to withhold inhalers and any steroid based medications. Synacthen performed at 08:30am: Pre Cortisol level: 96mmol/lPost Synacthen administration: 388mmol/lInadequate response to synacthen (adequate response is >480 nmol/lat 30 mins post synacthen). ACTH: negative Medically, the patient was started on hydrocortisone, 10/5/5 but this had little effect on the original symptoms of fatigue. She was also advised to reduce her mild opioid medication, as this should have a positive effect on the adrenal glands and in time should mean we can reduce the hydrocortisone medication. Two months later the patient had a hydrocortisone day curve test, mainly because she was reporting a 1.5 stone weight gain. HDC are preformed using the Imperial college hospital guidelines, pre medication and one hour after medication.
Results: Pre levels less than 30mmol/l, 10 mg hydrocortisone given post blood test 579mmol/lPre lunchtime levels was 317mmol/l, 5 mg hydrocortisone given post blood test 625mmol/lPre late afternoon levels was 295mmol/l, 5 mg hydrocortisone given post blood test 731mmol/lIt was suggested we reduce the 4pm dosage slightly to 2.5 mg. Other than that there was no changes were made. A further two months past and the patient contacted us to say she had stopped her hydrocortisone medication as the weight gain was getting worse. She reports she did not feel any different and she also informed us she has stopped her Tramadol medication. At the point the best option was to start again with a synacthen test. Pre cortisol level: 69mmol/lPost synacthen cortisol level: 357mmol/lThe patient was encouraged to restart hydrocortisone at a lower dosage 5 mg twice daily. We are now at present day and the plan to date is do a day curve again after a further few weeks.