How to lower cortisol levels?

How to Lower Cortisol Levels

Medical management of hypercortisolism is primarily achieved with adrenostatic agents such as ketoconazole (400-1200 mg/day) due to its availability and relatively tolerable toxicity profile. 1

Identifying the Cause of Elevated Cortisol

Before implementing strategies to lower cortisol, it's important to determine the underlying cause:

• Evaluate for Cushing syndrome with 24-hour urine cortisol measurement if cortisol levels are elevated 1
• Check ACTH levels to determine source of excessive cortisol:
  • Elevated ACTH suggests pituitary tumor or ectopic source (lung, thyroid, pancreas, bowel) 1
  • Normal/low ACTH with high cortisol suggests adrenal source (adenoma or carcinoma) 1
• Consider adrenal imaging to evaluate for tumors or hyperplasia 1

Medical Management Options

Pharmacological Interventions

• First-line pharmacotherapy: Ketoconazole at doses of 400-1200 mg/day is most commonly used for hypercortisolism 1
• Alternative medication: Mitotane can be used as an adrenostatic agent 1
• For ectopic Cushing syndrome: Consider octreotide if the tumor is Octreoscan-positive, though it may be less effective than in other contexts 1

Surgical Interventions (When Indicated)

• For adrenal adenomas: Laparoscopic adrenalectomy when feasible 1
• For ectopic ACTH-producing tumors: Surgical removal if possible 1
• For bilateral adrenal hyperplasia with asymmetric cortisol production: Unilateral adrenalectomy of the most active side 1
• For unresectable ectopic tumors or symmetric cortisol production: Bilateral adrenalectomy 1

Non-Pharmacological Approaches to Lower Cortisol

Stress Management Techniques

• Mindfulness meditation: Significantly reduces serum cortisol levels (from 381.93 nmol/L to 306.38 nmol/L in one study) 2
• Relaxation techniques: Show medium positive effect size (g = 0.347) in reducing cortisol levels 3

Dietary Modifications

• Higher carbohydrate intake: As part of a healthy whole food diet based on Dietary Guidelines for Americans can reduce cortisol levels and dampen stress-related cortisol responsiveness 4
• Avoid very low carbohydrate diets: Short-term low-carbohydrate diets (<35% carbohydrate) can moderately increase resting cortisol (0.41 [0.16,0.66]) 5
• Avoid severe caloric restriction: Low-calorie dieting (1200 kcal/day) increases total cortisol output 6

Post-Treatment Management

• Patients who undergo adrenalectomy require postoperative corticosteroid supplementation until recovery of the hypothalamus-pituitary-adrenal (HPA) axis 1
• Regular monitoring of cortisol levels is necessary to ensure normalization 1
• For patients with symptoms secondary to increased adrenocortical steroid levels, address specific issues such as hypertension, hyperglycemia, hypokalemia, and muscle atrophy 1

Cautions and Pitfalls

• Always rule out adrenal insufficiency before attempting to lower cortisol levels 1
• Rapid withdrawal of cortisol-lowering medications can precipitate adrenal crisis in patients who have developed dependence 1
• Patients on corticosteroids for management of other conditions will have low morning cortisol as a result of iatrogenic, secondary adrenal insufficiency 1
• Endocrine consultation is strongly recommended before initiating cortisol-lowering therapies 1