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.
Q&A from June 2024
Question: Is it okay to use topical hydrocortisone to support during a crisis?
Answer: Topical steroids should never be used to treat adrenal insufficiency - neither acute or chronic. Topical steroids are used to treat skin diseases and inflammation only. It does not provide a significant blood level of glucocorticoid that would substitute for oral or injectable steroids.
Question: What is happening in the body during emotional stress if the body is not naturally producing cortisol?
Answer: 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.
Question: How should medication be managed with time zone changes when traveling and should you stress dose?
Answer: 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.
Question: How long do I wait to run renin activity, after changing my dose of Florinef? My renin continues to be going up, regardless of my dosing, so I need the time frame in which I can measure renin activity
after I’ve changed my dose.
Answer: Reduction in plasma renin after an increase in fludrocortisone dose is fairly slow. Usually, it is rechecked
at the next clinical visit, but if you are concerned about it, I suggest waiting a month before repeating the renin level.
Question: I had Cushing’s disease and a macroadenoma pituitary tumor removal in 2011. With Cushing’s, I stopped my cycle in my late 30s and experienced menopause symptoms in my late 40s, including horrible hot flashes. Post surgery, my pituitary gland is not functioning, and I take thyroid and hydrocortisone. Just recently, I started getting hot flashes again! I am very confused by this, I am 60 years old.
Answer: The recurrence of hot flushes at this time in your life is, indeed, confusing. I suggest a visit with your endocrinologist to get some new baseline hormone levels. You should be menopausal at this age, and the hypopituitarism caused by the surgery 13 years ago would likely eliminate the normal pituitary gonadotropin (FSH and LH) increase typical of a woman of 60. One possibility is a partial recovery of residual pituitary production of FSH and LH. Another possibility is excess thyroid hormone dosing causing hyperthyroidism that may mimic menopausal heat intolerance.
Answer: Topical steroids should never be used to treat adrenal insufficiency - neither acute or chronic. Topical steroids are used to treat skin diseases and inflammation only. It does not provide a significant blood level of glucocorticoid that would substitute for oral or injectable steroids.
Question: What is happening in the body during emotional stress if the body is not naturally producing cortisol?
Answer: 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.
Question: How should medication be managed with time zone changes when traveling and should you stress dose?
Answer: 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.
Question: How long do I wait to run renin activity, after changing my dose of Florinef? My renin continues to be going up, regardless of my dosing, so I need the time frame in which I can measure renin activity
after I’ve changed my dose.
Answer: Reduction in plasma renin after an increase in fludrocortisone dose is fairly slow. Usually, it is rechecked
at the next clinical visit, but if you are concerned about it, I suggest waiting a month before repeating the renin level.
Question: I had Cushing’s disease and a macroadenoma pituitary tumor removal in 2011. With Cushing’s, I stopped my cycle in my late 30s and experienced menopause symptoms in my late 40s, including horrible hot flashes. Post surgery, my pituitary gland is not functioning, and I take thyroid and hydrocortisone. Just recently, I started getting hot flashes again! I am very confused by this, I am 60 years old.
Answer: The recurrence of hot flushes at this time in your life is, indeed, confusing. I suggest a visit with your endocrinologist to get some new baseline hormone levels. You should be menopausal at this age, and the hypopituitarism caused by the surgery 13 years ago would likely eliminate the normal pituitary gonadotropin (FSH and LH) increase typical of a woman of 60. One possibility is a partial recovery of residual pituitary production of FSH and LH. Another possibility is excess thyroid hormone dosing causing hyperthyroidism that may mimic menopausal heat intolerance.