Q&A from March 2024
Question: Is it safe for those with adrenal insufficiency to get multiple vaccines in one day, for example flu, COVID and or RSV? Should there be a few days spaced out between them?
Answer: I do recommend all 3 of the current virus immunizations - the influenza, RSV and new covid vaccine for individuals with adrenal insufficiency. Although the CDC indicates that all 3 can be given in one day, my personal opinion is that it is prudent to take no more than 2 at a time.
Question: Is it possible to have both PAI & SAI?
Answer: Primary adrenal insufficiency is due to damage, destruction or removal of both adrenal glands, leading to deficiency of both glucocorticoids (cortisol) and mineralocorticoids (aldosterone) and is treated with replacement hydrocortisone and fludrocortisone. Secondary adrenal insufficiency is due to a suppression or absence of secretion of ACTH from the pituitary gland in the head. The lack of ACTH stimulation to the adrenal glands leads to a deficiency of cortisol, but usually does not affect aldosterone production. Therefore, treatment is usually with glucocorticoids alone. The most common cause of SAI is the prolonged use of high dose steroids for other diseases, suppressing ACTH. If that is the cause, recovery may be possible if the steroid treatment can be tapered and discontinued. When ACTH deficiency is due to pituitary or hypothalamic disease or tumors, recovery is less likely. The possibility of PAI and SAI at the same time is unlikely, but not impossible. One scenario is SAI from steroid use and then a coincidental development of autoimmune adrenal disease or bilateral adrenal hemorrhage causing destruction of the adrenal glands. The most important issues in management are understanding whether there is a need for mineralocorticoid replacement and whether there is a potential for recovery.
Question: Has an Addisonian ever reported reflex syncope on the morning after vaccination. I had this even though I doubled the dose of hydrocortisone. Also, last year I had a fever and fainted without losing complete consciousness.
Answer: Reflex syncope, better known as vasovagal syncope, is a very common phenomenon. It is not due to Addison’s disease. Usually, it is in response to a trigger, such as seeing blood, fear of pain or any emotional distress. Sometimes a heavy meal with alcohol can trigger it. The vagus nerve to the stomach is stimulated, leading to a slowing of the heart rate and a sudden drop in blood pressure. This results in decreased blood flow to the brain and ultimately fainting. Typical early symptoms are pale skin, lightheadedness, blurry vision, nausea, a warm feeling in the face followed by a cold sweat. If caught early, loss of consciousness may be prevented by quickly lying on the floor to increase blood flow to the head. If loss of consciousness does occur, there may be twitching movements. The whole episode usually lasts less than a minute. The only danger is injury from hitting your head on furniture or the floor. Since in this case it did not occur immediately after the vaccination (that could have triggered it from fear of needles), the episode one day later was a coincidence. It was not necessary to take extra steroids, only fluids. It is not appropriate to avoid vaccinations. If you had an episode at the time of a vaccination, I would recommend that you recline for several minutes after the next shot, just as we recommend for some people who faint when giving a blood sample.
Question: I’m supposed to have a Botox injection on a muscle, and I wanted to make sure there was no contraindication for Addison’s Disease. Can you help with that?
Answer: Botox acts as a local long-acting muscle relaxant. The injections are not very painful and the effect is not stressful. There is no contraindication for anyone with adrenal insufficiency and no need to take extra glucocorticoids.
Question: I have been treated for Addison’s since 2005 when I almost died from hyponatremia. I have been taking hydro/fludro since then with zero problems. A family member needs a kidney. Could I donate?
Answer: Addison’s disease is not an absolute contraindication for live kidney donation. However, since kidney transplants are handled regionally, each region and hospital facility may reject you based on their own criteria and aversion to risk. In addition to the Addison’s disease, they will evaluate other medical issues, including age, other illnesses, kidney function and medication use. If they feel that the surgical removal of one of your kidneys presents an excessive risk to you, they will turn you down.
Answer: I do recommend all 3 of the current virus immunizations - the influenza, RSV and new covid vaccine for individuals with adrenal insufficiency. Although the CDC indicates that all 3 can be given in one day, my personal opinion is that it is prudent to take no more than 2 at a time.
Question: Is it possible to have both PAI & SAI?
Answer: Primary adrenal insufficiency is due to damage, destruction or removal of both adrenal glands, leading to deficiency of both glucocorticoids (cortisol) and mineralocorticoids (aldosterone) and is treated with replacement hydrocortisone and fludrocortisone. Secondary adrenal insufficiency is due to a suppression or absence of secretion of ACTH from the pituitary gland in the head. The lack of ACTH stimulation to the adrenal glands leads to a deficiency of cortisol, but usually does not affect aldosterone production. Therefore, treatment is usually with glucocorticoids alone. The most common cause of SAI is the prolonged use of high dose steroids for other diseases, suppressing ACTH. If that is the cause, recovery may be possible if the steroid treatment can be tapered and discontinued. When ACTH deficiency is due to pituitary or hypothalamic disease or tumors, recovery is less likely. The possibility of PAI and SAI at the same time is unlikely, but not impossible. One scenario is SAI from steroid use and then a coincidental development of autoimmune adrenal disease or bilateral adrenal hemorrhage causing destruction of the adrenal glands. The most important issues in management are understanding whether there is a need for mineralocorticoid replacement and whether there is a potential for recovery.
Question: Has an Addisonian ever reported reflex syncope on the morning after vaccination. I had this even though I doubled the dose of hydrocortisone. Also, last year I had a fever and fainted without losing complete consciousness.
Answer: Reflex syncope, better known as vasovagal syncope, is a very common phenomenon. It is not due to Addison’s disease. Usually, it is in response to a trigger, such as seeing blood, fear of pain or any emotional distress. Sometimes a heavy meal with alcohol can trigger it. The vagus nerve to the stomach is stimulated, leading to a slowing of the heart rate and a sudden drop in blood pressure. This results in decreased blood flow to the brain and ultimately fainting. Typical early symptoms are pale skin, lightheadedness, blurry vision, nausea, a warm feeling in the face followed by a cold sweat. If caught early, loss of consciousness may be prevented by quickly lying on the floor to increase blood flow to the head. If loss of consciousness does occur, there may be twitching movements. The whole episode usually lasts less than a minute. The only danger is injury from hitting your head on furniture or the floor. Since in this case it did not occur immediately after the vaccination (that could have triggered it from fear of needles), the episode one day later was a coincidence. It was not necessary to take extra steroids, only fluids. It is not appropriate to avoid vaccinations. If you had an episode at the time of a vaccination, I would recommend that you recline for several minutes after the next shot, just as we recommend for some people who faint when giving a blood sample.
Question: I’m supposed to have a Botox injection on a muscle, and I wanted to make sure there was no contraindication for Addison’s Disease. Can you help with that?
Answer: Botox acts as a local long-acting muscle relaxant. The injections are not very painful and the effect is not stressful. There is no contraindication for anyone with adrenal insufficiency and no need to take extra glucocorticoids.
Question: I have been treated for Addison’s since 2005 when I almost died from hyponatremia. I have been taking hydro/fludro since then with zero problems. A family member needs a kidney. Could I donate?
Answer: Addison’s disease is not an absolute contraindication for live kidney donation. However, since kidney transplants are handled regionally, each region and hospital facility may reject you based on their own criteria and aversion to risk. In addition to the Addison’s disease, they will evaluate other medical issues, including age, other illnesses, kidney function and medication use. If they feel that the surgical removal of one of your kidneys presents an excessive risk to you, they will turn you down.