NADF NEWS® Q & A – 2023
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On this page you will find questions and answers from the quarterly published NADF News.
Written by Paul Margulies, MD, FACE, FACP, Medical Director, NADF. Clinical Associate Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell. |
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Q&A from March 2023
Question: Is there a connection between ADHD, ADD and Addison’s Disease?
Answer: I am not aware of any connection between ADHD, ADD and Addison's disease, and I have not encountered it in my clinical practice. Since these disorders are quite common, it would be expected that some individuals with Addison's might have this as well.
Question: Is it possible to have taken too much sodium in a diet (popcorn and olives) and resultant equilibrium changes and elevated blood pressure. I stopped Florinef x2 days then started to feel better. Third day did a 1/2 of normal dose. Been on Florinef for 20 years. Never had this where I had to hold on to walls, furniture etc. to stand. It took me 5 days to get back to normal. I drink lots of water routinely.
Answer: It is possible to consume too much sodium, causing high blood pressure. Since the fludrocortisone tells the kidneys to retain sodium, temporarily reducing the dose will correct it. One concern, however, is this may be a sign that you are developing essential hypertension, perhaps as a familial risk. I suggest that you monitor BP on your normal dose of fludrocortisone for any trends toward higher readings. If BP is often higher than in the past, discuss options with your endocrinologist. When hypertension does develop in Addison's, the usual first approach is to reduce the maintenance dose of fludrocortisone. Sometimes a non-diuretic antihypertensive medication is added.
Question: My endocrinologist told me that I'm unable to build muscle tissue and get stronger from disciplined exercise. Is that true?
Answer: Glucocorticoids do contribute to wasting and atrophy of muscles, especially the proximal muscles (closer to the body) in the arms and legs. This is called steroid atrophy. It will occur when there is prolonged exposure to doses above the normal physiologic dose. In treating adrenal insufficiency, we try to keep the replacement dose below that level, so there is a smaller risk of atrophy. If there is atrophy from previous exposure, but the dose is now stable, there is the potential to regain strength in these muscles over time. If there is a lot of atrophy, it can take many months to regain the strength with exercise and good nutrition, including adequate protein. There may be other factors in your situation that may contribute to a lack of muscle recovery, such as other diseases or medications and age. Older people have a much harder time regaining muscle. Discuss this with your endocrinologist.
Question: Do you know if it's very common for someone to get Addison's Disease as a result of immunotherapy for treating cancer? I assume there have been few, if any, clinic trials with patients like me because all my doctors have been unable to answer 90 percent of my questions.
Answer: Yes, we do know that immunotherapy that is used for a variety of cancers can cause adrenal insufficiency. It can actually cause primary or secondary adrenal insufficiency. When the medications activate the immune system, they can induce autoimmune adrenal insufficiency that injures the adrenal glands - Addison's disease. Another pathway is to cause autoimmune hypophysitis. This is inflammation in the pituitary. That inflammation may reduce the production of ACTH, leading to secondary adrenal insufficiency, plus disruption of other pituitary hormones, including thyroid and gonadal function. The most common endocrine effect from these medications is thyroid changes - either hyperthyroidism or hypothyroidism. Sometimes these effects may resolve over time.
Question: Would it be appropriate for someone with primary adrenal insufficiency to get the pneumococcal vaccine?
Answer: I do recommend that anyone with adrenal insufficiency get the pneumonia vaccination. The current one is the Prevnar 20.
Question: Can long term steroids cause stomach ulcers? If so, how do individuals with Addison’s continue to take their medication without causing further damage?
Answer: Oral glucocorticoids can cause acid-peptic symptoms and an increased risk of ulcers. It is usually seen in people who take high doses, especially over a long time. The doses used for adrenal insufficiency are lower, replacement doses. These doses are much less likely to contribute to stomach symptoms and injury. However, some individuals may be more sensitive. If acid peptic symptoms do occur, adding antacid medications or taking the medication with food can prevent the symptoms and damage.
Question: My son has Addison's disease. When should he take his medications in preparation for lab tests?
Answer: The timing of lab tests will vary depending on what the clinician is looking for. If you are trying to assess the baseline adrenal function, the AM fasting cortisol and ACTH levels are useful, and must be obtained before any medication. If you want to assess the adequacy of replacement medications, blood tests for electrolytes and plasma renin may be taken anytime during the day after the normal dosing of medications in the morning and afternoon. This would not include serum cortisol or ACTH. If an ACTH stimulation test is performed, it must be before any glucocorticoid is taken.
Answer: I am not aware of any connection between ADHD, ADD and Addison's disease, and I have not encountered it in my clinical practice. Since these disorders are quite common, it would be expected that some individuals with Addison's might have this as well.
Question: Is it possible to have taken too much sodium in a diet (popcorn and olives) and resultant equilibrium changes and elevated blood pressure. I stopped Florinef x2 days then started to feel better. Third day did a 1/2 of normal dose. Been on Florinef for 20 years. Never had this where I had to hold on to walls, furniture etc. to stand. It took me 5 days to get back to normal. I drink lots of water routinely.
Answer: It is possible to consume too much sodium, causing high blood pressure. Since the fludrocortisone tells the kidneys to retain sodium, temporarily reducing the dose will correct it. One concern, however, is this may be a sign that you are developing essential hypertension, perhaps as a familial risk. I suggest that you monitor BP on your normal dose of fludrocortisone for any trends toward higher readings. If BP is often higher than in the past, discuss options with your endocrinologist. When hypertension does develop in Addison's, the usual first approach is to reduce the maintenance dose of fludrocortisone. Sometimes a non-diuretic antihypertensive medication is added.
Question: My endocrinologist told me that I'm unable to build muscle tissue and get stronger from disciplined exercise. Is that true?
Answer: Glucocorticoids do contribute to wasting and atrophy of muscles, especially the proximal muscles (closer to the body) in the arms and legs. This is called steroid atrophy. It will occur when there is prolonged exposure to doses above the normal physiologic dose. In treating adrenal insufficiency, we try to keep the replacement dose below that level, so there is a smaller risk of atrophy. If there is atrophy from previous exposure, but the dose is now stable, there is the potential to regain strength in these muscles over time. If there is a lot of atrophy, it can take many months to regain the strength with exercise and good nutrition, including adequate protein. There may be other factors in your situation that may contribute to a lack of muscle recovery, such as other diseases or medications and age. Older people have a much harder time regaining muscle. Discuss this with your endocrinologist.
Question: Do you know if it's very common for someone to get Addison's Disease as a result of immunotherapy for treating cancer? I assume there have been few, if any, clinic trials with patients like me because all my doctors have been unable to answer 90 percent of my questions.
Answer: Yes, we do know that immunotherapy that is used for a variety of cancers can cause adrenal insufficiency. It can actually cause primary or secondary adrenal insufficiency. When the medications activate the immune system, they can induce autoimmune adrenal insufficiency that injures the adrenal glands - Addison's disease. Another pathway is to cause autoimmune hypophysitis. This is inflammation in the pituitary. That inflammation may reduce the production of ACTH, leading to secondary adrenal insufficiency, plus disruption of other pituitary hormones, including thyroid and gonadal function. The most common endocrine effect from these medications is thyroid changes - either hyperthyroidism or hypothyroidism. Sometimes these effects may resolve over time.
Question: Would it be appropriate for someone with primary adrenal insufficiency to get the pneumococcal vaccine?
Answer: I do recommend that anyone with adrenal insufficiency get the pneumonia vaccination. The current one is the Prevnar 20.
Question: Can long term steroids cause stomach ulcers? If so, how do individuals with Addison’s continue to take their medication without causing further damage?
Answer: Oral glucocorticoids can cause acid-peptic symptoms and an increased risk of ulcers. It is usually seen in people who take high doses, especially over a long time. The doses used for adrenal insufficiency are lower, replacement doses. These doses are much less likely to contribute to stomach symptoms and injury. However, some individuals may be more sensitive. If acid peptic symptoms do occur, adding antacid medications or taking the medication with food can prevent the symptoms and damage.
Question: My son has Addison's disease. When should he take his medications in preparation for lab tests?
Answer: The timing of lab tests will vary depending on what the clinician is looking for. If you are trying to assess the baseline adrenal function, the AM fasting cortisol and ACTH levels are useful, and must be obtained before any medication. If you want to assess the adequacy of replacement medications, blood tests for electrolytes and plasma renin may be taken anytime during the day after the normal dosing of medications in the morning and afternoon. This would not include serum cortisol or ACTH. If an ACTH stimulation test is performed, it must be before any glucocorticoid is taken.
