What are the treatment options for high Dehydroepiandrosterone sulfate (DHEAS) and low cortisol levels?

Treatment for High DHEAS and Low Cortisol Levels

The primary treatment for high DHEAS and low cortisol levels is hydrocortisone replacement therapy, typically starting with 15-20 mg daily in divided doses (10-15 mg in the morning, 5-10 mg in the early afternoon). 1

Diagnosis and Evaluation

Before initiating treatment, confirm the diagnosis with:

• Morning cortisol and ACTH levels
• Comprehensive adrenal function testing
• Evaluation for primary vs. secondary adrenal insufficiency
  • Primary: High ACTH, low cortisol
  • Secondary: Low ACTH, low cortisol

The combination of high DHEAS with low cortisol suggests a potential dissociation in adrenal hormone production, which requires careful evaluation.

Treatment Algorithm

Step 1: Glucocorticoid Replacement

• First-line therapy: Hydrocortisone 15-20 mg daily in divided doses 2, 1
  • Morning dose: 10-15 mg
  • Afternoon dose: 5-10 mg
• Hydrocortisone is preferred over prednisone or dexamethasone due to:
  • Shorter half-life
  • Better mimicry of natural cortisol rhythm
  • More precise titration 1

Step 2: Mineralocorticoid Replacement (if needed)

• For primary adrenal insufficiency with mineralocorticoid deficiency:
  • Add fludrocortisone 0.05-0.1 mg daily 2
  • Target upper half of reference range for renin 2

Step 3: Monitor and Adjust

• Regular monitoring of:
  • Clinical symptoms
  • Morning cortisol levels
  • DHEAS levels
  • Electrolytes (sodium, potassium)
  • Blood pressure

Research shows that hydrocortisone therapy can help normalize elevated DHEAS levels. In one study, patients receiving hydrocortisone showed significant reductions in DHEAS levels toward normal ranges 3.

Special Considerations

Stress Dosing Education

All patients must receive education on stress dosing:

• Double or triple the usual dose during minor illness
• Use injectable hydrocortisone for emergencies
• Wear a medical alert bracelet for adrenal insufficiency 2, 1

Monitoring DHEAS Levels

• High DHEAS levels may correlate with greater disability in some conditions 3
• DHEAS typically decreases with hydrocortisone treatment 3
• Extremely low DHEAS can be a marker of exhausted adrenal reserve in critical illness 4

Tapering Considerations

If the patient has been on prior glucocorticoid therapy:

• Gradual tapering is essential
• Reduce total daily dose by 2.5 mg every 2-4 weeks
• Slower reduction for patients with longer duration of prior glucocorticoid use 1

Common Pitfalls to Avoid

1. Starting thyroid hormone replacement before corticosteroids in patients with multiple hormonal deficiencies, which can precipitate adrenal crisis 2

2. Failing to provide stress dosing education, which can lead to adverse outcomes during illness or procedures 2, 1

3. Using long-acting glucocorticoids (prednisone, dexamethasone) for replacement therapy, which don't mimic natural cortisol patterns as well as hydrocortisone 1

4. Tapering too rapidly, which can precipitate adrenal crisis 1

5. Not recognizing that DHEAS and cortisol recovery may be dissociated, with DHEAS remaining suppressed for a longer period after treatment 5

By following this treatment approach, patients with high DHEAS and low cortisol can achieve hormonal balance and improved clinical outcomes.