From the FDA Drug Label
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From the Research
For a 70-year-old female with a morning cortisol of 40 nmol/L and PTH of 76 ng/L, I recommend immediate referral to an endocrinologist for further evaluation of likely adrenal insufficiency and possible secondary hyperparathyroidism. The cortisol level is significantly below the normal morning range (typically 170-540 nmol/L), suggesting adrenal insufficiency which requires urgent attention 1. While awaiting specialist consultation, consider initiating hydrocortisone replacement at 15-20 mg daily in divided doses (typically 10-15 mg in the morning and 5 mg in the afternoon) after confirming the diagnosis with an ACTH stimulation test. The elevated PTH (normal range typically 15-65 ng/L) suggests parathyroid dysfunction, which may be related to vitamin D deficiency or calcium abnormalities, as seen in primary hyperparathyroidism (PHPT) or secondary hyperparathyroidism (SHP) 2, 3. Some key points to consider in the management of this patient include:
- Order additional tests including serum calcium, phosphate, vitamin D, ACTH level, and electrolytes to further evaluate the patient's condition.
- Monitor for symptoms of adrenal crisis such as fatigue, weakness, hypotension, nausea, and confusion.
- Educate the patient about stress dosing of hydrocortisone during illness and provide a medical alert bracelet.
- Consider vitamin D supplementation if deficiency is found, as it may help reduce PTH levels without causing hypercalcemia or hypercalciuria 3. The combination of low cortisol and elevated PTH could indicate a complex endocrine disorder requiring comprehensive evaluation, as these findings may be interrelated or represent separate conditions requiring different treatment approaches 4, 5.