Written by Paul Margulies, M.D, F.A.C.E., F.A.C.P. Medical Director, NADF.
Clinical Associate Professor of Medicine, New York University Medical School.
Q&A from March, 2017
Question: Are there studies in Addison’s disease patients who anticipate need for Kidney disease dialysis? I am 84 years old. I was diagnosed with Addison’s disease 36 years ago. I am now at stage 3 CKD… Nephrologist wants me to “investigate dialysis” for possible future needs. I have to continually adjust my needs for electrolytes. Wouldn’t that increase my needs for extreme monitoring in dialysis?
Answer: Dialysis in persons with Addison’s disease is a challenge, but it can be done. The fluid shifts and electrolyte balances can be dealt with by experienced nephrologists. Generally, the hydrocortisone dosage would remain stable, but fludrocortisone would no longer be useful because it works on the kidneys.
Question: Are there any new appetite suppressants that are safe for adrenal insufficient patients?
Answer: I do not support the use of appetite suppressants for anyone, whether they have adrenal insufficiency or not. Despite the approval of some of these medications by the FDA, I am not impressed with the long term benefit of any of them. Among the otherwise healthy obese, most regain the weight they lost while on these drugs within the next 6 to 12 months. Short term, these drugs are generally stimulants that may cause irritability, sleep disturbance and gastrointestinal symptoms. I support the use of portion control diets along with exercise.
Question: I know that people with adrenal insufficiency are prone to hypoglycemia, before diagnosis or when under-medicated. Have you ever had a patient whose hypoglycemia actually caused them to crave sugar?
Answer: If a person who tends to have hypoglycemia learns that taking sugar relieves the symptoms, they may develop the habit of craving sugar when they get those symptoms again. This can be true with any cause of hypoglycemia. Many people have “reactive hypoglycemia” where symptoms occur 2 hours after eating carbohydrate. Often the glucose level is actually normal, but feels low because it is dropping after the robust insulin response to the carbohydrate. It turns out that preventing the symptoms by eating a protein snack is better that responding to the symptoms with sugar. In any case, whether in adrenal insufficiency, diabetes, or reactive hypoglycemia, sugar should be used only as last resort. A balanced diet is best.
Question: My doctor has told me that dexamethasone is an adequate adrenal crisis care injectable, but you recommend hydrocortisone. Is there a reason one is better than the other?
Answer: Dexamethasone has no mineralocorticoid activity, and has a very long duration of action that misses the physiologic diurnal variation. It is only available as 0.5 mg in 5 ml. That is a very big injection if given into a muscle and the dose would be inadequate. I disagree with your doctor for the reasons stated.