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Found 90 matches in 54 Q&A's.


1) Q&A from the December, 2004 NADF newsletter:

QUESTION: Four years ago I had an operation for colon cancer that took 37 inches of my colon out. Since then it has traveled and is now in my lungs and may be in other places. I have talked with the cancer doctors who want me to take chemotherapy. I have studied the booklets they gave me and I have determined that I will be worse off if I get these treatments. There is Emend for controlling vomiting, then there is Eloxatin and Avastin for the chemo tube. I have been to the ER quite a few times with Addisonian problems and I simply cannot face this awful intrusion into my system. I was diagnosed with Addison's disease when I was 40 and could hardly walk. I am 73 now and get along pretty well. I have secondary Addison's and take 20 mg. of Cortef daily. Could you please advise me what I should do? I am strongly tempted to take the time I have left and enjoy it.

ANSWER: The decision you have to make regarding your quality of life with chemo is a difficult one. The coincidence of adrenal insufficiency should not be much of a factor in your decision, however. You will probably need to increase your dose of hydrocortisone to handle the stress and nausea, but that is the easy part. Doubling or even tripling the dose will have marginal side effects compared to either the chemo or the cancer. I have had many adrenal insufficiency patients undergo chemo and get through quite well. Good luck.



2) Q&A from the March, 2005 NADF newsletter:

QUESTION: I read all kinds of stuff regarding cardio-fitness. And I read all kinds of stuff saying that we with adrenal problems should not exert ourselves longer than 45 minutes or excess cortisol kicks in and will further stress our bodies. Can you give me some general guidelines as to length of time we can exercise in total and of that time how much should be spend on exertion vs. just a gentle heart rate increase? I hope that makes sense.

ANSWER: I believe everyone should try to stay physically fit with regular exercise and good diet. There is no specific restriction on exercise for people with Addison's disease. For general fitness, I suggest an aerobic routine like a treadmill for 30 minutes with added training exercises like weights if desired. There is nothing wrong with doing more exercise - just listen to your body. Make sure you stay well hydrated and replace salt as needed, especially if you are exercising in hot weather. If the exercise causes excess fatigue, it may be necessary to add a little extra hydrocortisone before the next routine. Start with an extra 5 mg and go up from there if needed.



3) Q&A from the June, 2005 NADF newsletter:

QUESTION: I have a question regarding possible interference of methotrexate with Cortef. I was put on methotrexate (7.5 mg once a week) for rheumatoid arthritis about early October. It didn't help; in fact I began to feel worse, but we were finishing a new house, moving in, etc. and I attributed this to stress. Early December the dosage was increased to 10 mg per week. I began to feel REALLY HORRIBLE. Weak, upset stomach, weepy—it's hard to describe how awful I felt. My normal dose of Cortef was 25-30 mg per day (10- 10-5). I had gone to 60 mg per day and it didn't seem to help. I started going through my files regarding Addison's and came across a short blurb about drug interference with cortisone. I discussed it with my PCP (not an endocrinologist as none are available in this area). We decided to drop the methotrexate about mid- December. I began to feel better as of early February. I am wondering if the methotrexate is indeed the culprit, how long it should take to get this out of my system and if there is something I could take in place of it. I would prefer not taking anything at this time if I can avoid it. Too many pills.

ANSWER: I am not aware of any interference in cortisone metabolism from methotrexate. The fact that increasing the hydrocortisone dosage didn't help suggests that it was not the adrenal insufficiency that made you feel bad, it was the methotrexate. Many people can't tolerate it. I am not able to suggest other treatment for the RA. You need a rheumatologist to review your condition and your previous drug effects.



4) Q&A from the September, 2005 NADF newsletter:

QUESTION: I have read that diagnosing adrenal fatigue can be very tricky and there are many types of different tests. Could you please share with me as to which one you think is the most accurate?

ANSWER: “Adrenal fatigue" is not a recognized medical diagnosis. Addison's disease is the correct term for primary adrenal insufficiency and is diagnosed with an abnormal lack of response to ACTH or Cortrosyn, elevated levels of ACTH, positive 21-OH antibodies (if autoimmune) and characteristic symptoms and physical findings. Clearly, people with Addison's disease must go through a period of relative loss of adrenal reserve before they present with the full set of abnormalities of total adrenal failure. During that phase there may be partial adrenal insufficiency that may give test results that are in between normal and classic Addison's. I would use the term early or partial adrenal insufficiency not “adrenal fatigue". I think that term is used by people who propose that the adrenals “wear out" from various stresses and miss the point that Addison's disease is not caused by stress, but by specific injury from antibodies, hemorrhage, infections, tumors, or surgery.



5) Q&A from the March, 2006 NADF newsletter:

QUESTION: My father has been on some form of steroid everyday for the past 20+ years for rheumatoid arthritis. Is it possible to get completely off this drug after so many years?

ANSWER: Tapering off long term steroids used to treat chronic illness like rheumatoid arthritis is usually difficult, and is harder with very long term use like this. The first issue is what is the dose of steroid used. If prednisone over 5 mg or Medrol over 4 mg is used for many years, the adrenals have been totally suppressed all that time and are less likely to work again. Another issue is the state of the disease being treated. There is no point in reducing the dose of steroid if the disease is still very active, unless another drug can be substituted. Once the taper is started, if the disease symptoms flare, then the steroid dose must be increased again. Even if tapering is successful, it will take about a year for the adrenal responsiveness to be normal and during that year, steroids will be needed to handle stress. Most of the time, after 20 years of steroid use, a stable replacement regimen like prednisone 5 mg is the easiest solution.



6) Q&A from the March, 2006 NADF newsletter:

QUESTION: My daughter was recently diagnosed with Schmidt's syndrome. In addition, she has had a headache for over a year. The headache gets somewhat better at times, and is worse at others, but never goes away. We still do not have a diagnosis on the headache, although tension seems to be a significant contributor. Due to the headache pain and the fatigue associated with Addison's, she has become depressed. Could the Addison's and Hashimoto's be causing her headache? She had scoliosis surgery a year ago in November and now has two Titanium alloy rods in her back. Could a metal allergy have caused the onset of Addison's? She developed low blood pressure and orthostatic intolerance two weeks after surgery. Could this have actually been an Addison's crisis and we are just fortunate that she still was making enough Cortisol to get through the surgery? Could a difficult menstrual cycle be stressful enough to require an extra 5mg of cortisol?

ANSWER: Depression is common in individuals with inadequate treatment of both adrenal insufficiency and hypothyroidism, but it is also common in the general population and in the setting of chronic illness. Headache can also be seen in hypothyroidism. Metal allergy is not a known cause of adrenal insufficiency. Certainly, hypotension after surgery may have been a sign of adrenal insufficiency at that time. Yes, menstrual cramps can be severe enough to require extra steroid treatment. Try a dose of ibuprofen at the onset of the cramps to minimize the pain.



7) Q&A from the September, 2006 NADF newsletter:

QUESTION: I would be grateful if you could you tell me what type of an impact continued severe emotional stress can have on someone suffering from secondary adrenal deficiency caused through the presence of a pituitary tumor.

ANSWER: Emotional stress can cause significant symptoms of adrenal insufficiency in primary as well as secondary causes. Under normal pituitary-adrenal conditions, emotional stress would tend to promote an increase in ACTH and cortisol production. Since this does not happen in adrenal insufficiency disorders, the body feels like there is a lack of cortisol. Typical symptoms would be fatigue, lethargy, loss of appetite, weakness, dizziness and depression. Just as in cases of physical stress, one needs to remember to increase the dosage of glucocorticoid replacement. Laboratory tests are not very useful in this circumstance. If prolonged use of higher doses leads to signs of cortisol excess, then cut back to the lowest dose that keeps you feeling better. Also, try to deal with the cause of the emotional stress, if possible.



8) Q&A from the December, 2006 NADF newsletter:

QUESTION: I had Addison's for 11 years, and now have hypothyroid condition. Adding Synthroid, I am getting CRAZY. Whenever I have to raise steroids (infection, stress, etc.) it causes me to go very HyPOthyroid. Then when I lower the steroids & taper down, I go very hyPERthyroid!!"

ANSWER: As you know, hypothyroidism and Addison's disease will commonly occur together, and there is usually no conflict. Each replacement must be handled separately. Typically, hypothyroidism will start with partial insufficiency and a mild replacement dose, but will usually slowly progress with further loss of thyroid function, and the replacement dose will increase to fill the gap. In contrast, when Addison's disease is diagnosed, a full replacement dose of glucocorticoid and mineralocorticoid is necessary right away, and the adjustment in dose is based on body size, activity, and stress levels in daily living. Doses of glucocorticoid, such as hydrocortisone, have only a minor affect on thyroid hormone levels. Often, high doses make one feel “hyper" without necessarily changing blood levels, and may be followed by a feeling of let-down that feels like “hypo". On the other hand, since higher doses of hydrocortisone are given for stressful illnesses that may cause fatigue that feels like hypothyroidism, and are then relieved at the time the steroids are tapered, which may contribute to the inverse symptoms you describe. The best way to check is to look at the blood levels, especially of TSH as a guide to thyroid replacement.



9) Q&A from the March, 2007 NADF newsletter:

QUESTION: Is Addison's Disease getting in the way of me healing from a herniated disc? Is the medicine I am on going to interfere with any pain pills I might be on? I am on hydrocortisone 20mg am/10mg pm fludrocortisone acetate 0.1 am Synthroid 112mcg am. What pain pills would help if I have a choice to go on any? Sometimes the pain can be very intense.

ANSWER: I cannot advise you about which pain medication is appropriate for you. I can tell you that pain is a stress that often makes your body need more steroid hormone. If you notice more fatigue, loss of appetite, nausea or dizziness, these are signs indicating you need more hydrocortisone. Also, some narcotic pain medications increase the rate of metabolism of the hydrocortisone, which may also make you need a higher dose. The actual healing of the disc problem will not be affected by the Addison's disease.



10) Q&A from the June, 2007 NADF newsletter:

QUESTION: I just read the email on decreasing your cortisone. I have been on 30mg for 27 years and I have tried to decrease it to 25mg. I only gave it about a week because I was tired. Do you think I should give it longer and see how I feel since the high dosage it not good for us? Please let me know what you think. Thanks.

ANSWER: Although I maintain that most Addisonians can and should get by with lower doses of hydrocortisone, it is not appropriate for everybody. Each Addisonian has his or her own personal medical situation that will affect their steroid needs. Other medical conditions, other medications, stresses, ability to exercise, mood, age, weight are just a few of the variables. Talk to your doctor about all of this before trying to taper the dose again.



11) Q&A from the December, 2007 NADF newsletter:

QUESTION: I have a question about supplemental vitamins. I have been told that because I have celiac and Addison's, I should be taking many supplemental vitamins. I see a nutritionist and belong to a support group for celiac and I get a lot of mixed messages. The biggest problem I have is that it seems no one, even my doctors, know that much about Addison's. It has been a year since I was diagnosed with Addison's and a year and a half with celiac disease. I work a stressful job and feel that I need to retire or find another job, as I have many times when my sodium level has been low. I now know when to recognize this so that I do not have to be hospitalized each time. Any help you can give me would be appreciated. Thank you.

ANSWER: There is no specific vitamin regimen necessary for Addison's disease. However, I usually suggest a general multivitamin/mineral supplement to a good healthy diet. Extra calcium is very important, especially for post-menopausal women. The celiac disease tends to cause a malabsorption of vitamin D. I suggest that anyone with celiac disease have a serum 25-OH vitamin D level checked. If it is low, adding extra vitamin D is essential. Doses of 800 to 1200 U per day are useful for normal to slightly low D levels. If the blood test shows very low levels (below 20), then prescription strength vitamin D should be given and monitored by your doctor.



12) Q&A from the March, 2008 NADF newsletter:

QUESTION: Is there any information on steroid dosing in high altitude conditions? It affects breathing, I believe, and I thought I read somewhere that we should up our steroid replacement a bit for the altitude stress.

ANSWER: An interesting question that I have not been asked before. I found one study on adding fairly low dose glucocorticoids to normal people suddenly dropped off at a high altitude. It showed that the steroids (in the equivalent of prednisone 10 mg) helped them function better than people not treated. I have not seen a study of Addisonians, but extrapolating the data, it would make sense to increase the dose of hydrocortisone in an Addisonian by 20 to 30 mg for acute high altitude exposure. If a gradual increase in altitude is encountered, this would probably not be necessary. Also, after prolonged exposure to high altitude, the body adjusts and extra steroids would not be required.



13) Q&A from the June, 2008 NADF newsletter:

QUESTION: I am a 54 year old female who was diagnosed with Addison's Disease five years ago. For a long time, I have wanted to try one of the dermal fillers for the deep folds around my mouth. Is there one that is safe and effective for me to use? I have asked my endocrinologist, but he is not familiar with the products. I have an appointment with my dermatologist next month to have some keratoses removed. I would like to talk with him about the fillers at that time.

ANSWER: I am not familiar with these products either. I can't think of any reason you would not be able to use a skin therapy that is safe and effective for other people. As long as it does not cause any serious stress on your body, the Addison's disease should not be a factor.



14) Q&A from the June, 2008 NADF newsletter:

QUESTION: I'm a 67-yr. old female with Addison's and hypothyroidism. My concern is my fluctuating, sometimes very high ACTH numbers, which I started logging in 1989. I'm frightened of an increased hydrocortisone dose. My stomach is quite distended since the beginning of year and I have gotten thick in waist area. I have also developed terrific loss of bone in my jaw the last few years. I felt much better on a lower dose. My question is: What is the highest “safe ACTH read" recorded? I know we all react differently to some medications and I really do not want to take more steroids. I sometimes feel they do more damage than good. PLEASE HELP!

ANSWER: Stop measuring ACTH. The level has no clinical value after the initial diagnosis of Addison's disease. The dose of hydrocortisone should be adjusted to the clinical response - sense of well being, energy, stamina, weight gain or loss, blood pressure fluctuations, appetite, etc. It is important to take enough hydrocortisone to eliminate the symptoms of adrenal insufficiency while avoiding excessive replacement that will cause signs and symptoms of cortisol excess. Useful blood tests include electrolytes (sodium and potassium), and plasma renin (especially for adjusting the dose of fludrocortisone). If there is significant hyperpigmentation despite hydrocortisone, this is a clinical sign of high ACTH. Usually the hyperpigmentation will resolve when the dose is adequate, but may temporarily return at times of stress. This can be useful as a guide to therapy, but should be used in conjunction with the other signs and symptoms of adrenal insufficiency in making adjustments in dosage.



15) Q&A from the September, 2008 NADF newsletter:

QUESTION: Would a temporary use (a few days to a couple of weeks) of St. John's Wort, in a small dosage, interfere with prednisone/hydrocortisone, Florinef and Synthroid? If St. John's Wort is not appropriate, are there any other supplements that could be used to help dealing with stress. My son has a very tough semester in school. The stress level cannot be healthy for anyone, especially for someone with an autoimmune disease.

ANSWER: There is no interference between antidepressants and steroid replacement for Addison's disease. However, you need to understand that St. John's Wort is an over the counter serotonin reuptake inhibitor that is basically like a very low dose of Prozac. The effects are very mild, but like the other SSRI's, takes about a month to work. It should not be considered a treatment for short term stress. In my opinion, if there really is a severe emotional reaction to academic stress, a therapist or prescription medication would be needed. If it is simply the usual college stress, try relaxation techniques.



16) Q&A from the September, 2008 NADF newsletter:

QUESTION: Why is it that when I am in a stressed situation that has caused sleeplessness, I can take cortisol and it puts me to sleep within 30 minutes? Is this normal? Also, trying to cut back on asthma inhaler Symbicort 160/4.5 which I think has led to nasal blockage (similar to a cold without congestion) and problems sleeping and tiredness. My allergist has no idea how to address my Addisons....I have secondary Addison's from chemo. Hope you can help me figure this out.

ANSWER: There are two questions here. stress leading to sleeplessness would tend to require extra glucocorticoid therapy to handle the stress. I presume when the extra dose is taken, it helps to relieve the stress symptoms and adds to a more relaxed state. It does not cause the sleep directly. The use of steroid containing inhalers for asthma in the setting of secondary adrenal insufficiency can be tricky. As long as the usual baseline dose of glucocorticoid is sufficient and was not reduced when the inhaler was added, tapering slowly from the inhaler should not present much of an adrenal insufficiency effect. I would be more concerned about a return of asthma symptoms



17) Q&A from the March, 2009 NADF newsletter:

QUESTION: My 20 year old son is a member of NADF because he has Addison's. His endo of 11 years died and he has a new one now. He is 165 pounds and she recommends he injects 200 mg of solu-cortef if there is an emergency. His previous endo rec 100mg. What is the dosage used by adult Addisonians? I fear that if he uses too much, it will be detrimental instead of helpful. I would appreciate any help you can give us with this question.

ANSWER: A stress dose of 100 mg of hydrocortisone (Solu-Cortef is hydrocortisone) is adequate for emergencies while waiting for transportation to a health care facility. Keep in mind that the average human produces about 20 to 35 mg of cortisol per day. When stressed, we will produce more. The typical suggested stress dose of 100 mg every 8 hours IV or IM given in hospitals for medical emergencies or surgery is purposely an exaggeration of the normal physiologic response, but is generally safe. Although there is no significant long term ill effect of giving an acute dose of 200 mg in an emergency, it is much more than necessary, and might temporarily raise blood sugar and lower potassium.



18) Q&A from the June, 2009 NADF newsletter:

QUESTION: I am a member of NADF because I've had Addison's for the last 7 years and I am hoping you can help me because I have not gotten a reply from my endocrinologist. I will be having an angiogram and I need to know how to prepare for this. Is there anything special that my cardiologist needs to do before doing the angiogram? Thank you for your prompt reply and assistance on this matter.

ANSWER: An angiogram is not as stressful as surgery, so IV Hydrocortisone is usually not needed. I would still suggest contacting your own endocrinologist, but I can recommend taking a double dose of your usual morning hydrocortisone before going for the angiogram. Remind the cardiologist about your condition and have him contact your endocrinologist if there are any postprocedure issues that might necessitate giving you extra doses of hydrocortisone.



19) Q&A from the March, 2010 NADF newsletter:

QUESTION: I have a son who has Addison’s disease. His current medications are Dexamethasone and Florinef. Can you tell me how significant contracting Herpes is to someone who has an Addison’s diagnoses? Thank you!

ANSWER: I assume we are referring to genital or oral herpes. It can be controlled quite well with antiviral medication, often given continuously, or sometimes as needed when there is a flare up. It should have no effect on the Addison’s disease because it rarely causes a systemic illness that would require a stress dose of steroids.



20) Q&A from the December, 2010 NADF newsletter:

QUESTION: This past year, for no known reason, my Addison’s has escalated with 9 adrenal crisis hospitaliztions. This March and April were back to back. We are looking for a root cause with abnormal results for both liver and lungs. I’m interested if NADF has any knowledge on this subject. Any information would be very much appreciated. Thanks so much!

ANSWER: I cannot speculate about the specific cause of the changes. Certainly any other medical problem, including liver or lung disease can have an impact on the metabolism of the replacement glucocorticoids, or produce extra stress that would necessitate extra steroid dosing. A thorough evaluation of any abnormalities is needed.



21) Q&A from the December, 2010 NADF newsletter:

QUESTION: While researching information for a new flyer an NADF volunteer was working on, she found information on Wikipedia that Addisonians may have raised calcium levels in blood. Have you heard about it?

ANSWER: Hypercalcemia can occur in Addison’s disease and I do see it frequently in my patients. It is generally mild and asymptomatic. I see it most often at times of stress when there is a relative insufficiency of hydrocortisone and may accompany mild hyperkalemia (high potassium). If it persists when adrenal replacement is in balance, it is a good idea to check parathyroid hormone just rule out hyperparathyroidism as a cause of the elevated calcium.



22) Q&A from the March, 2011 NADF newsletter:

QUESTION: Have any special advice for menopausal adrenal insufficient women dealing with sweats?

ANSWER: Treatment for menopausal flushes and sweats remains a problem. The only therapy that works is hormone replacement with estrogen, but this introduces risks, including an increase in breast cancer risk. If the symptoms are severe, a low dosage of hormone replacement may be useful for a short period of time - like 6 to 12 months, using the lowest dose that works, and tapering off slowly (this assumes no current breast or other contraindication). Over the counter remedies are generally plant estrogens that rarely help. Some antidepressant drugs, such as Effexor have been shown to help, but can have side effects, including weight gain. For most women it is best to tough it out. Addisonian women will, indeed, sometimes need a little bit of extra hydrocortisone for stressful episodes, but be careful to avoid taking too much to cover the stress and wind up with weight gain and other features of cortisol excess.



23) Q&A from the September, 2011 NADF newsletter:

QUESTION: I have adrenal insufficiency, diagnosed about 5 years ago. I always have a problem with doctors & health care professionals not knowing much about this disease & especially not knowing the protocols for adrenal insufficient patients when running tests and procedures. My Gastro doctor has ordered a Gastrografin Enema for me. I don’t know much about this test. I have asked the radiologist questions, but he really can't help me in finding out if I will need any kind of hydration or steroids during this test. Can you help me out? Are you aware of any protocol that needs to be followed for this test, for me?

ANSWER: An enema to look at the colon is not a very significant stress. I would expect that you might need to be on a liquid diet for a day, but as long as you are well hydrated at the time of the procedure, it is unlikely that extra IV fluids or steroids would be needed. However, if you are dealing with any pain or serious discomfort, a slight increase in oral hydrocortisone before the procedure would be safe.



24) Q&A from the December, 2011 NADF newsletter:

QUESTION: I am a 56 year old female who has had secondary pituitary adrenal insufficiency for 11 years. My supplemental steroids is prednisone. I have developed cataracts in both eyes and now I need surgery to remove them. My endo is recommending 100 cc of solumedrol presurgery and 20 mg of oral prednisone after and for 2 days then 10 mg the third day. He will then wean me from there. Does this seem like an appropriate dose for the cataract surgery? He had me receive the IV steroids for endo/colonoscopies and for the removal of my lateral meniscus. Some of my past medical history includes MRSA of both eyes 9 years ago, bletheritis of both eyes with allergies, severe asthma, bilateral hip replacements, osteoporosis and sleep apnea. Thank you for your input.

ANSWER: I think the suggested stress dosage of steroids is quite excessive for cataract surgery. This does not involve general anesthesia and is very fast and not much of a stress on the body. I usually suggest no extra steroids for cataract surgery, or at most an extra 5 mg of prednisone (or an extra 20 mg of hydrocortisone for an Addisonian) to be taken orally before the procedure.



25) Q&A from the June, 2012 NADF newsletter:

QUESTION: What does it mean when the cortisol level is lower in the morning, and higher in the late afternoon-evening?

ANSWER: Normal people have a peak cortisol level just before they wake up in the morning and the level gradually decreases through the day, usually reaching near zero by midnight. Typically, people with adrenal insufficiency have lower than normal cortisol levels all the time, but the values may overlap with normal, so an ACTH stimulation test is more accurate in sorting out whether there is a normal reserve. People with Cushing’s syndrome have cortisol levels higher than normal, but again it can overlap with normal. However, in Cushings there is usually a lack of variation during the day, and the midnight cortisol is elevated rather than zero. As to why someone might have an inverted cycle, it depends. There may be a missleading inversion if that person is taking any steroid preparation, which may supress the morning value. If there is much stress, normal people can increase their cortisol production in the afternoon. It is important to look at the clinical context, the use of medications that might affect the values, and the absolute numbers for that time of day.



26) Q&A from the March, 2013 NADF newsletter:

QUESTION: I have secondary adrenal insufficiency, and for the last 10 years I have found that in a pinch, squirting the hydrocortisone solution of my crisis care injection into my mouth and swallowing it works if I can't inject myself with the hypodermic needle. Is this a good way to treat an Addisonian crisis?

ANSWER: I do not recommend this approach. Since the purpose of an emergency injection is to provide a high dose when oral medication would be ineffective (especially if the person is vomiting), giving the injectable form into the mouth is not more effective than taking more pills by mouth. I suppose the injectable forms, like Solucortef would be absorbed, since it is a solution of hydrocortisone in sodium succinate. But if the individual is vomiting, the amount absorbed would still be uncertain. I would still suggest increased oral steroids for stressful events, IM hydrocortisone for emergencies when oral cannot work, and ER visits for IV saline and hydrocortisone when those treatments do not work. It is possible that squirting Solucortef into the mouth may help if there is no other steroid available, but it is not the ideal treatment.



27) Q&A from the September, 2013 NADF newsletter:

QUESTION: I’m an Addisonian, and also a sufferer of chronic pain. I feel like one can affect the other sometimes. Are the two in some way related, or can chronic pain lead to adrenal failure over a period of time?

ANSWER: Pain is a stress that can affect the management of Addison’s disease, and opiates prescribed for chronic pain can affect the metabolism of replacement steroids. But, pain does not cause the destruction of the adrenal glands.



28) Q&A from the March, 2014 NADF newsletter:

QUESTION: I have adrenal insufficiency as well as numerous other medical conditions. I experience chronic pain because of those conditions, and have been taking opiates for years to manage it. Due to a problem with supplying my pain medication, I have been approached with the idea of using naltrexone to try and quickly break my dependency on opiates. There is not yet a plan for a replacement method to treat my pain. What is your opinion of using naltrexone therapy as an adrenal insufficient patient?

ANSWER: Using naltrexone is certain to cause severe pain. It is very important to manage the use of any narcotic with adrenal insufficiency. Narcotics can increase metabolism of glucocorticoids, and not enough of either pain medication or cortisol can further increase pain. Finding a balance is difficult, requiring frequent adjustments to dosages of pain medication and steroids. However, I cannot recommend using naltrexone if the opiates you are on are necessary to fight chronic pain. Naltrexone is usually only used for overcoming narcotic addiction, and it sounds like you need pain management. Without pain management, naltrexone will only further complicate your adrenal insufficiency since pain is a severe stress.



29) Q&A from the March, 2014 NADF newsletter:

QUESTION: I have adrenal insufficiency, and need to go in for intravenous immunoglobulin (IVIG). Should I take a stress dose of steroids in preparation for the treatment?

ANSWER: Definitely discuss your adrenal insufficiency and stress dosing concerns with the doctor prescribing the IVIG. Glucocorticoids like hydrocortisone are commonly given to people undergoing IVIG to treat potential reactions, even if they aren’t adrenal insufficient. Anyone with adrenal insufficiency will then likely need them, but the dosage should be worked out between you and your doctor.



30) Q&A from the June, 2015 NADF newsletter:

QUESTION: Colonoscopies can be a terror to many. Dehydration and nausea are big factors, and prevents many from going through with them. I’m very concerned about the effects of both the preparation and procedure causing someone with adrenal insufficiency to go into crisis. What sort of precautions can patients take to help them?

ANSWER: The cleanout protocols have changed and are now gentler. There is no need for inpatient colonoscopy unless there are other significant medical problems, like severe heart disease or a history of complications from previous colonoscopies. As always, I recommend individualization of steroid management, so if the prep causes nausea or severe cramps, extra hydrocortisone should be used to cover those symptoms on the prep day. However, if the cleanout just causes the usual diarrhea, and appropriate fluids are used to avoid dehydration, a normal steroid dose that day will be sufficient. My recommendation for a slight extra dose on the morning of the procedure stands, although even that is probably not needed in most cases. But again, a higher dose can be used if there are other stressors. I continue to recommend that the anesthesiologist be prepared to give IV hydrocortisone if needed.



31) Q&A from the September, 2015 NADF newsletter:

QUESTION: I am aware of recommended surgery protocol for adrenal insufficient patients. Are there recommendations for the 2nd and 3rd day post-surgical, bilateral knee replacement therapy as one begins ambulation?

ANSWER: The speed of steroid taper post-op depends on the severity of the post-op stress, which usually means pain. After knee replacement, narcotics are typically used, and these affect the steroid dosage indirectly. It would be common to need a double oral dosage for the first 2 or 3 days post-op. If pain is well controlled, a taper to 1 and 1/2 of the usual oral dose may be needed for several more days until pain is limited. If there are any surgical complications, such as infection, a return to higher stress doses would be needed. When in doubt, if any adrenal insufficiency symptoms occur, such as nausea or dizziness, continue to take extra glucocorticoids.



32) Q&A from the March, 2016 NADF newsletter:

QUESTION: What is the protocol for taking a chemical cardiac stress test? Is it safe to do?

ANSWER: Despite the term stress test, these tests do not cause significant enough stress to warrant any additional glucocorticoid coverage for people with adrenal insufficiency. Whether it is a chemical stress test or a treadmill test, it is physiologically like taking a very brisk walk or jog for several minutes.



33) Q&A from the June, 2016 NADF newsletter:

QUESTION: I have been working for the USPS for 12 years but all indoors. I recently made the switch to letter carrier and was wondering if you know of any research or any information about heat, the sun and so on. I live in New Mexico and summers are always in the high 90’s and I just want to better prepare myself for summer if I can. I have tried looking on line but only found anecdotal and hearsay into about Addison’s and the sun. So I would like to find more clinical info. Any help would be grateful!

ANSWER: The recommendations really apply to anyone exposed to the heat. Wear a hat, wear loose clothing, and stay well hydrated. Assuming secondary adrenal insufficiency rather that primary, dehydration is less of a threat. Although salt loss is less of an issue for people with secondary adrenal insufficiency, I would add salty foods or snacks if lightheadedness or dizziness is a common occurrence. Extra glucocorticoid doses are needed only if severe stress symptoms occur, including nausea, cramping and profound fatigue.



34) Q&A from the September, 2017 NADF newsletter:

QUESTION: I was diagnosed with Addison’s Disease when I was 23 years old. I’m a female and have since gone on to have three healthy children and have led a very productive life. For the first 20 years, I was treated with Prednisone and Florinef. About 6 or so years ago, my doctor switched me to 15mg of Hydrocortisone a day, along with 0.1mg of the Florinef. I also take 50mg of Zoloft (which was prescribed to help deal with extra anxiety since I do not produce extra cortisone when I’m feeling stressed). I am now 49 years old and feel that I might be entering menopause - I have been having severe irritability, and anxiety and depression. It’s like a cloud has descended over me and I actually feel the weight of it on my chest. I’ve always had short bouts of blueness but they never lasted very long and I think they have been related to my cycle however now the bouts of blueness and depression have settled in and aren’t lifting. I am wondering if hormone changes will require additional help with my steroid usage?

ANSWER: Menopause itself does not necessarily require an adjustment in hydrocortisone dosage. However, I think it is time to discuss with your endocrinologist how you are feeling. Since all of the hydrocortisone is taken in the morning, it might be worthwhile considering a restructuring of the dosage to have some in the morning plus a little in the afternoon. Also, consider a change in the Zoloft - perhaps an increase in dose, or a change to something else. If the menstrual cycle has stopped and there are significant flushes and night sweats that disturb sleep, consider adding a low dose of hormone replacement therapy if there is no contraindication. This may help with sleep, energy and mood.



35) Q&A from the March, 2018 NADF newsletter:

QUESTION: I have Addison’s, and I’m going in for an MRI soon. I’m getting the procedure to check my heart, with and without contrast. I got anxious the last time I was in an MRI machine, and felt like I needed extra hydrocortisone. Is there any recommended procedure for this?

ANSWER: Getting an MRI does not cause any physical stress. If there is a severe emotional reaction to the claustrophobia of the study, it is OK to take along an extra 5 mg of hydrocortisone to be given. However, this is really unlikely to be needed.



36) Q&A from the March, 2018 NADF newsletter:

QUESTION: I have secondary adrenal insufficiency. My adrenal glands are small and produce cortisol with proper diet and care. stress will put me into crises. When I go into crises I lose all muscle control so it is a race of time to get me to the ER. I was born with only the right thyroid, and now have nodules on it. I have hypothyroidism and tried armor and levothyroxine, which I’ve had allergic reactions to. My father had thyroid nodule cancer. If I need to have the right thyroid removed because of cancer, is their medication for me to take for the thyroid that will not damage my adrenal glands?

ANSWER: There are mistaken concepts about adrenal insufficiency as well as thyroid disease. The simple answer to the question is that thyroid hormone in the form of levothyroxine would be necessary if the remainder of the thyroid is removed. Levothyroxine cannot be allergenic. If allergic symptoms occurred in the past, it was to the inert ingredients in the tablet. One way to avoid that is to use a liquid form of levothyroxine in the brand Tirosint®. Thyroid hormone cannot damage the adrenals.



37) Q&A from the March, 2018 NADF newsletter:

QUESTION: Q.I was diagnosed with Addison’s disease recently after I had a seizure from hypotension. I am a urologic surgeon and am supposed to return to work. I am worried that the stress of my job (which is unpredictable and variable) will be difficult to manage. I take call regularly and cover 3 hospitals simultaneously while doing so often as long as 7 days straight or more. I worry that the periodic confusion that I experience now (i.e. I walked out of a store and forgot to pay) may limit my ability to always be correct as my job requires. I am wondering if there are other surgeons with the disorder who can confirm that they have been able to continue to work as I do now. I have to worry about not only the lives of my patients but also my life as I am only 40 years old. Any resources that you can help me with would be greatly appreciated. I am even stressed thinking about work right now.

ANSWER: I certainly understand your concern. I do not have any surgeons with Addison’s disease in my practice at this time, although I do have an emergency room physician who performs very well at his job, plus a few nurses and medical technicians. I think the major challenge you face is the unpredictability of the hours and work stress. You are going to have to learn how to monitor your stress to develop a pattern of glucocorticoid therapy that works for you. Start with “normal” days with normal hours of work, allowing normal meal breaks and rest, and find a dosage of glucocorticoids and mineralocorticoids that keeps you comfortable. Then, by trial and error, find the amount of extra hydrocortisone that you need to add for specific types of extra stresses, such as a prolonged surgery or excessive physical exertion, or later than normal hours. Always carry extra hydrocortisone tablets with you. You will gradually learn how to offset each type of stress with a specific extra dose. It will take time, but it can be done. Don’t give up on your career!



38) Q&A from the June, 2018 NADF newsletter:

QUESTION: I have secondary adrenal insufficiency, but my adrenal glands produce enough cortisol if I manage my stress and health. I only need hydrocortisone in a crisis. I have hypothyroidism, and only my right thyroid gland, but it has developed nodules and it may need to be removed. I think I’m allergic to levothyroxine, so I was wondering if there is a medication for me that will not damage my adrenal glands?

ANSWER: There are some mistaken concepts about adrenal insufficiency as well as thyroid disease. The simple answer to this question is that thyroid hormone in the form of levothyroxine would be necessary if the remainder of the thyroid is removed. One cannot be allergic to levothyroxine. If allergic symptoms occurred in the past, it was to the inert ingredients in the tablet. One way to avoid that is to use a liquid form of levothyroxine like in the brand Tirosint. Thyroid hormone cannot damage the adrenals.



39) Q&A from the March, 2019 NADF newsletter:

QUESTION: I have a child with adrenal insufficiency, and it’s time for them to get the medically recommended vaccinations. Is there a protocol for vaccinations in AI children?

ANSWER: NADF, CDC and most endocrinologists advocate universal vaccinations for all individuals with adrenal disorders, including AI. There are no guidelines mandating stress steroid coverage for vaccinations in children or adults, unless the person develops fever or other serious signs of illness. One should realize that the risk nowadays of acquiring measles, flu or other diseases is far greater and more life-threatening than any possible vaccine side effects. See CDC recommendations.



40) Q&A from the June, 2019 NADF newsletter:

QUESTION: I have Addison’s, and have had multiple outbreaks of shingles in a year. I haven’t gotten the new vaccine for shingles because I’m worried about how it will interact with my medication. Is there a protocol for this?

ANSWER: A new shingles vaccination is recommended even for people who have already had outbreaks. There are risks of reactions that could result in mild illness such as soreness and fever. The vaccination is usually given in two parts, two months apart. In the event of subsequent illness, the standard protocol for extra hydrocortisone dosing to cover the added stress should be taken, as well as things to treat a fever if it occurs. There is nothing to suggest shingles and Addison’s have any connection that would increase or affect outbreaks.



41) Q&A from the December, 2019 NADF newsletter:

QUESTION: I have been on steroids for 19 years for secondary AI and proton pump inhibitors (PPI) for 18 years due to the steroids. I’m now having side effects of long-term use of the steroids: thinning skin, bruising, thinning bones (stress fractures), increasing A1c, etc. I’ve also developed chronic reflux which has resulted in repeated sinus infections. My internal medicine physician has discussed the possibility of a Nissen fundoplication for the reflux. Do the endocrinologists at NADF know if there is success with this procedure due to having to be on steroids for the rest of your life? Does the stomach tissue thin with the chronic steroid use like your skin does with the long-term steroid use? In May I had a bleeder cauterized in my stomach and many polyps due to long term use of PPI’s. My ferritin was 9. Any feedback would be appreciated.

ANSWER: There are multiple issues presented here. First, long-term use of glucocorticoids can cause thinning and easy bruising of the skin and can contribute to bone loss. Generally, these effects are related to the dose of glucocorticoids as well as the length of time taken. If replacement doses, such as prednisone 5 mg per day or hydrocortisone 15 to 20 mg per day are used, these effects are minimized. However, some people are sensitive to even these or lower doses and may have the side effect anyway. If higher doses are used over many years, the side effects are more likely to appear. Most people on replacement steroids do not have significant acid-peptic problems. Acid reflux is a common problem in the general population, but may be aggravated if high dose steroids are needed. Unfortunately, the long-term use of proton pump inhibitors for acid reflux has been prevalent for a long time. We now recognize that these drugs can contribute to bone loss. I usually advise substituting H2 blockers such as Zantac or Pepcid in place of the PPIs. Surgery for the reflux is rarely needed, but if there is serious damage to the esophagus that cannot be controlled, it may be considered. There is no specific issue with the surgery in people with AI. The steroids should not cause thinning of the stomach tissue, but the upper endoscopy should provide information about the integrity of the stomach and esophageal anatomy. I would suggest a consultation with a gastroenterologist and a GI surgeon who has experience with this procedure.



42) Q&A from the March, 2020 NADF newsletter:

QUESTION: I was diagnosed with Addison’s disease in 1988. I was wondering if anyone has tried CBD (cannabidiol) products to help with tiredness, joint pain, and muscle aches. If so, does it help, and are there any downsides to it? Thanks for any info you can give.

ANSWER: CBD products are now available without prescription because they contain no THC, the active cannabinoid in marijuana. Unfortunately, since the products are over the counter, manufacturers and distributers can make claims about benefits and purity that are unsubstantiated. We need controlled studies and better verification on the potency of these products. I am not an expert in the use of CBD oil or other products, but some of my patients without adrenal disease have reported short term help with anxiety and stress with the oil. I have no experience with CBD in Addison’s disease. I would express caution until there is more research and more consistency in the available products.



43) Q&A from the June, 2020 NADF newsletter:

QUESTION: I’ve read that anti-inflammatory drugs can cause viral immunity suppression and should be avoided right now due to COVID-19. Are steroids to treat adrenal insufficiency also a problem?

ANSWER: The fear about the COVID-19 virus is causing confusion, some of it coming from health authorities that make statements that are then used in different contexts. That is probably the reason for this confusion. First, it has nothing to do directly with NADF’s previous statements about individuals with adrenal insufficiency. Our recommendation for treating an individual with adrenal insufficiency who gets sick from any infection has not changed: take extra glucocorticoids according to the degree of symptoms and fever; treat the fever, hydrate and rest. Both acetaminophen and ibuprofen are effective in lowering fever. I generally favor acetaminophen primarily because it is less likely to cause heartburn or affect blood pressure, but I consider ibuprofen to be a safe choice. Some articles lump “anti-inflammatory drugs” with ibuprofen and glucocorticoids. This is inaccurate. Although we know that higher doses of glucocorticoids over time may have a mild effect on viral immunity, that does not mean we should stop treating acute infections with the appropriate stress doses to get through the acute illness.



44) Q&A from the June, 2020 NADF newsletter:

QUESTION: I was put on a high dose of hydrocortisone due to a serious illness that led to hospitalization. Do you have any advice to taper down after two days of high doses (7 doses of 100 mg, every 6 hours)? My endocrinologist put me on a 10-day regiment to taper down. Is that needed?

ANSWER: The rate of taper is based on the clinical status of the patient, not the diagnosis of adrenal insufficiency. A slow taper of 10 days would be appropriate if you are still ill and need continued stress dosing of the hydrocortisone. If you are completely back to normal and have good blood pressure, and are able to eat normally, then a more rapid taper would be appropriate.



45) Q&A from the March, 2021 NADF newsletter:

QUESTION: I would appreciate any advice about adrenal insufficiency that is caused by opioid use, especially how it might affect treatment compared to other cases of AI.

ANSWER: Opioid-induced adrenal insufficiency is quite common. It has been estimated that between 9 to 29% of chronic opioid users develop some degree of adrenal insufficiency. The mechanism is suppression of the hypothalamic-pituitary responsiveness to the need for cortisol, so there is a relative deficiency of ACTH stimulation to the adrenals, resulting in inadequate cortisol production. This can produce a full spectrum of adrenal insufficiency symptoms, from negligible to full adrenal crisis if there is an acute precipitating illness or injury. The diagnosis is confirmed with a blunted cortisol stimulation test, but simply finding a low AM serum cortisol with a low ACTH level is sufficient. This is a form of secondary adrenal insufficiency, not Addison’s disease. The treatment is the same as other forms of secondary adrenal insufficiency: usually hydrocortisone, but prednisone would also work. There is no need for fludrocortisone. Some important notes: OIAD is more likely with higher doses of opioids and longer duration of usage. It is potentially reversible if opioids can be discontinued. Finally, since the need for replacement glucocorticoids will increase in times of stress, if pain is not controlled with the opioid use, a higher dose of glucocorticoids may be needed.



46) Q&A from the June, 2021 NADF newsletter:

QUESTION: Should individuals with adrenal insufficiency stress dose prior to receiving the COVID-19 vaccine?

ANSWER: I do not advise using extra glucocorticoids on the day before or on the day of vaccination. I suggest the individual with adrenal insufficiency wait to see if significant side effects occur, usually the day after the vaccine. If there is fever, significant muscle aches and pains, and especially nausea or any typical adrenal insufficiency symptoms, I would then add stress dose steroids in addition to treating any fever with acetaminophen or ibuprofen. I have spoken to many of my patients about their experiences, and many report no side effects at all. Those that did have significant symptoms were individuals who had a history of acute Covid-19 infection earlier in the year, and then had the vaccine.



47) Q&A from the June, 2021 NADF newsletter:

QUESTION: I have never seen any guidance on what to do if we have a severe allergic reaction (anaphylaxis) to something. My guess is that we would need both SoluCortef (or equivalent) and epinephrine. Would there be a problem if we were given only epinephrine without the SoluCortef?

ANSWER: The immediate treatment for anaphylaxis is epinephrine. If this were to occur in a person with adrenal insufficiency, I would recommend adding a stress dose of hydrocortisone 20 mg to cover the stress. IV or IM hydrocortisone would be appropriate only if there is a sustained allergic reaction after the use of epinephrine.



48) Q&A from the March, 2022 NADF newsletter:

QUESTION: Should individuals with Adrenal Insufficiency take potassium? I was always told not to.

ANSWER: Primary adrenal insufficiency causes an elevation in serum potassium due to the deficiency of aldosterone. Since this hormone is not deficient in secondary adrenal insufficiency, potassium levels are usually normal in that condition. People with PAI or Addison’s disease should not take potassium supplements since it would add to the tendency for high levels from stress or inadequate hydrocortisone or fludrocortisone dosage. Generally, when replacement doses are adequate and stress levels are normal, there is no need to eliminate high potassium foods, but it is not advisable to purposely add high potassium foods.



49) Q&A from the June, 2022 NADF newsletter:

QUESTION: I’m supposed to have an aggressive preparation for an upcoming colonoscopy and endoscopy. Is it safe to alter potassium and electrolytes for someone with Primary Adrenal Insufficiency (PAD?)​

ANSWER: The prep itself is safe for adrenal insufficiency. I recommend plenty of clear fruit juices like apple or white grape juice rather that Gatorade. The procedure itself is not stressful, but the anesthetist or anesthesiologist must know about the adrenal insufficiency and be prepared to give iv hydrocortisone only if the procedure goes much longer than expected or if there is a complication.



50) Q&A from the June, 2022 NADF newsletter:

QUESTION: I’ve had secondary AI for 10 years and feel confident in my ability to manage it on a daily basis but having watched my husband prep for his first colonoscopy recently, I feel some trepidation. After all, isn’t diarrhea one of the primary triggers of adrenal crisis? Colonoscopy preparation results in extreme diarrhea for several hours! I’d appreciate any guidance you can offer on what I need to discuss with my endocrinologist and my surgeon, and how I can limit the risk to my health during the preparation.

ANSWER: Despite the concern about the diarrhea, colonoscopy is not a cause for concern in people with primary or secondary adrenal insufficiency. During the prep day when medications are given to help with the clean out and clear liquids are necessary, if appropriate fluids are consumed there will be no need for extra doses of hydrocortisone. I do recommend using clear fruit juices like apple juice and white grape juice because they add needed calories. The procedure itself is also not stressful. Light anesthesia is used, not general anesthesia. Pre-surgical stress dosing of hydrocortisone is not needed. I would simply consider an extra dose of 10 mg orally before going to the procedure only if you feel very anxious. It is important to inform the physician doing the colonoscopy and the anesthesiologist about the adrenal insufficiency, so they are prepared to give IV hydrocortisone if the procedure is prolonged or there are any complications.



51) Q&A from the September, 2022 NADF newsletter:

QUESTION: What could be advice for someone who has experienced many adrenal crisis incidents over just the past 3 years (I've had it for 6 years this month.) I've been on hydrocortisone, prednisone, and am currently on a high dose of dexamethasone and have been on that high dose for two years. even with that, stress dosing when needed and doing other preventative measures my cortisol still hits the floor (.4 on average) to put me in the hospital.

ANSWER: It is difficult to determine what factors make you more prone to acute adrenal crises. Many factors could be involved, including occupation, family status that might expose you to more infections, other coexisting diseases, and the need for early recognition of the signs and symptoms that indicate that stress doses should be started immediately. I would recommend that you have an emergency Solu-Cortef vial and syringe, which might prevent the need for an ER visit in some situations. I am a bit puzzled about the switch to prednisone or high dose dexamethasone. If you have primary adrenal insufficiency, prednisone and dex have no mineralocorticoid activity. I assume you are taking adequate fludrocortisone. If not, your blood volume may be chronically low, keeping you too close to the threshold where blood pressure can drop and precipitate a crisis. Also, since you mention very low serum cortisol levels, keep in mind that when you are taking dexamethasone, the serum cortisol will be suppressed, so it will not be a useful test. Much better to go back to hydrocortisone.



52) Q&A from the September, 2022 NADF newsletter:

QUESTION: My doctor is prescribing Paxlovid for COVID. When I check it out online, I read that it alters the absorption of Cortef and Fludrocortisone. My doctor does not understand Addison’s, so he may not be aware of how crucial that absorption is. What is NADF advising regarding Paxlovid with Cortef and Fludrocortisone? I just read NADF article “FDA Approves Antiviral Pills……” along with its links. It does not address this issue.

ANSWER: Paxlovid is appropriate for individuals with adrenal insufficiency who have Covid. It has a minor effect on glucocorticoid metabolism, especially dexamethasone and prednisone, but not hydrocortisone or fludrocortisone. Even then, the effect is to raise the level, which is beneficial in the setting of symptomatic Covid. Individuals with adrenal insufficiency should increase their dosage of glucocorticoids to handle the stress of the acute illness. Any effect during the 5-day course of Paxlovid is helpful, not harmful. Since there are many other drugs that can interact with Paxlovid, they should be reviewed by the physician and pharmacist.



53) Q&A from the June, 2024 NADF newsletter:

QUESTION: Q: What is happening in the body during emotional stress if the body is not naturally producing cortisol?

ANSWER: A: stress, whether physical or emotional, will prompt an increase in cortisol production to increase blood pressure, blood glucose and help with mood stability. In the absence of an automatic surge in cortisol, the remaining physiologic responses to stress still provide a significant safety net. There will be a dramatic increase in catecholamines - epinephrine and norepinephrine (adrenalin) as well as growth hormone and glucagon. These hormones also increase blood pressure and glucose. There may be an increase in heart rate from the epinephrine. Of course, if the emotional stress is recognized, you should add an extra amount of glucocorticoid to supplement the usual dose, providing what the adrenal glands can no longer do.



54) Q&A from the June, 2024 NADF newsletter:

QUESTION: Q: How should medication be managed with time zone changes when traveling and should you stress dose?

ANSWER: A: I recommend trying to take the doses of medication according to the time where you are. If you are travelling east, the next dose will be needed sooner than usual, but will be rebalanced with the following dose. When travelling west, there will be a longer interval. If you are going more than 3 time zones west, it would be helpful to add a small extra dose of hydrocortisone in the middle of the journey.





Questions are normally submitted by NADF members.
Answers are from NADF's Medical Director Paul Margulies, M.D., FACE, FACP.

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NADF does not engage in the practice of medicine. It is
not a medical authority, nor does it claim to have medical
knowledge. In all cases, NADF recommends that you consult your
own physician regarding any course of treatment or medication.





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