Dr. Amy Nett: Okay, so let me go back and pull that case up. Week 29, case three. Okay, so case number three. It’s a 30-year-old female who initially presented with abdominal distension, weight gain, fatigue, Cryptosporidium, low levels of beneficial bacteria, impaired fasting blood glucose, and CRP. Then she has—okay, great. So, she has low total free cortisol but high free cortisol. Okay, great Leslie, Yeah, you’re absolutely right. So, this is actually sluggish clearance. In this case, there might be sluggish clearance—let’s see here—which we can see with poor liver function and hypothyroidism. Again, I don’t know that it always follows this trend. The other thing I think of, and I don’t know that there is a true mechanism for this or that we have elucidated it, but see how she has really low total cortisol, but her free cortisol is high? I sometimes wonder if the body has been in this really low cortisol state, if it’s trying to sort of protect itself in a way, like maintain more normal levels of free cortisol. You’re right. It is a sluggish clearance. What that is happening I don’t know. I didn’t mention her thyroid here, but I would definitely check her thyroid function, and to some extent, it might just be that inflammation is leading to sluggish clearance. We can sometimes see that with inflammation. I see this pattern again. I don’t know that that is documented, but it is something we see. She is favoring cortisol here, so more cortisol. It says this patient has weight gain, so I don’t remember if this patient was overweight, but things that are going to drive the free cortisol picture are going to be the high insulin, the obesity, and the inflammation. Okay, so you’re right. Sluggish clearance, so I did make a mistake on that last week if I said her clearance was rapid. You’re right—sluggish clearance. It would favor cortisol, so again, things that favor cortisol over cortisone do include the high insulin, visceral obesity, and inflammation, so that part would fit. It’s just going to be the sluggish clearance. Okay, hopefully I didn’t just confuse you more.
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- I’m confused about your answer to Justine in the Q&A last week about case number three in Week 29. You said that insulin favors cortisol over cortisone. So insulin potentially favors cortisol and that it produces increased clearance of cortisol. But in case number three, the patient had low cortisol metabolites and high-normal free cortisol. To me, that doesn’t make sense with your explanation.
I’m confused about your answer to Justine in the Q&A last week about case number three in Week 29. You said that insulin favors cortisol over cortisone. So insulin potentially favors cortisol and that it produces increased clearance of cortisol. But in case number three, the patient had low cortisol metabolites and high-normal free cortisol. To me, that doesn’t make sense with your explanation.
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