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Cortisol Screening in Chronic Pain Patients

Screening for cortisol serum levels can give treating clinicians an insight into whether patients with chronic pain are at risk for diabetes, hyperlipidemia, and osteoporosis.
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Depression and Cortisol
Cortisol serum levels may be high in depressed pain and non-pain patients.70,71 The relationship between pain, depression, and high serum cortisol levels is unclear and complicated, as patients with severe chronic pain invariably report depression until their pain is controlled. If patients state that their pain is poorly controlled at the time they demonstrate high cortisol levels, the first clinical endeavor should be to prescribe more analgesia. If patients report good pain control when they demonstrate high cortisol levels, assume depression and start an antidepressant. Also, the simultaneous administration of an opioid and antidepressant is often an optimal and recommended approach.

Should Other Hormones Be Tested?
Once you are comfortable with cortisol screening, I recommend that other hormones be simultaneously tested. Because abnormal (high or low) cortisol levels are fraught with so many complications and dangers to the patient, I recommend starting with cortisol. Other than cortisol, these endocrine tests may give you additional information as to whether chronic pain is over- or understimulating the hypothalamic-pituitary-adrenal-gonadal system: CRH, ACTH, pregnenolone, follicle-stimulating hormone (FSH), testosterone, and estradiol. To date, I don’t have enough information to make hard recommendations. In pain practice, our goal is somewhat different from that of the endocrinologist in that we are primarily seeking to control pain in the hope that the endocrine system will subsequently normalize. Other than cortisol, I find serum pregnenolone and testosterone screening to be particularly useful.

Pregnenolone, the precursor of cortisol, may be an even better biologic marker for pain control. Testosterone serum screening is important, as low levels lead to poor pain control, loss of tissue growth, depression, and loss of libido.72,73

Summary
Patients who complain of severe chronic pain—particularly when it is constant, disabling, and requires opioids for control—should be screened with a single, early-morning serum cortisol concentration. Uncontrolled pain (acute and chronic) initially shows a high serum cortisol concentration. If the pain has been severe and constant for a prolonged period, HPA suppression may occur, resulting in a low serum cortisol concentration. Low serum cortisol concentrations below 1.0 mg/dL should be considered an emergency and corticoid administration, in conjunction with vigorous pain relief, is in order. Prolonged high cortisol concentration may cause all of the serious complications of Cushing’s syndrome, including hypertension, hyperlipidemia, diabetes, osteoporosis, mental decline, and vertebral collapse. Vigorous medical management of pain often is required to keep abnormal (high or low) cortisol serum concentrations in a normal range and minimize the complications of hypercortisolemia and hypocortisolemia. Serum cortisol should be viewed as an essential biologic marker for adequate pain control.

Last updated on: June 5, 2017
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