Does Lupus Affect Cortisol?
Yes, lupus does affect cortisol levels, with research demonstrating that women with SLE and elevated inflammatory markers show significantly lower morning cortisol awakening levels compared to those with low disease activity. 1
Evidence of Cortisol Dysregulation in Lupus
The most direct evidence comes from a study examining cortisol patterns throughout the day in women with SLE. Patients with high erythrocyte sedimentation rate (ESR >20 mm/h) had significantly lower cortisol awakening levels compared to those with low ESR (≤20 mm/h), indicating hypothalamic-pituitary-adrenal (HPA) axis dysfunction correlates with disease activity. 1
Key Findings on Cortisol Patterns
- While both groups maintained the characteristic diurnal cortisol rhythm (highest in morning, declining through day), the awakening cortisol level was specifically blunted in patients with active inflammation 1
- This suggests that lupus-related inflammation may suppress the normal cortisol awakening response, potentially contributing to fatigue and other symptoms 1
Clinical Implications for Women of Childbearing Age
Impact on Glucocorticoid Therapy
This endogenous cortisol dysregulation becomes particularly relevant when managing lupus in women of childbearing age, as glucocorticoids remain a cornerstone of treatment but should be minimized to the lowest effective dose, ideally ≤7.5 mg/day prednisone equivalent 2, 3
The altered HPA axis function in active lupus may influence:
- Response to exogenous glucocorticoid therapy 4
- Risk of adrenal suppression with chronic steroid use 4
- Stress response capacity during pregnancy and postpartum periods 4, 2
Pregnancy Considerations
For women planning pregnancy, the interaction between lupus-related cortisol dysregulation and pregnancy-induced HPA axis changes requires careful monitoring, as pregnancy itself increases cortisol production 4, 2
- Hydroxychloroquine should be continued throughout pregnancy to maintain disease control and reduce flare risk, which may help stabilize HPA axis function 2
- Oral glucocorticoids at the lowest effective dose are safe during pregnancy when needed for disease control 2
- Active disease at conception significantly increases flare risk, potentially worsening cortisol dysregulation 2
Monitoring Recommendations
Disease activity should be assessed regularly using validated indices, including ESR and inflammatory markers, as these correlate with cortisol abnormalities 1, 3
Common Pitfall to Avoid
Do not assume that fatigue in lupus patients is solely due to disease activity or medication side effects—consider that blunted cortisol awakening response may be contributing to symptoms, particularly in patients with elevated inflammatory markers 1