NADF NEWS® Q & A – 2025
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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. Retired Clinical Associate Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell. |
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Q&A from January 2025
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.
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: My son has Addison’s Disease and Hashimoto’s. His thyroid was being overtreated which was discovered after his labs. He is now taking half the dose of his levothyroxine. This is good news! My question is, can his thyroid be getting better? If not, what can be the reason? He was diagnosed in 2018 and has been on half the dose since May of 2024.
Answer: First, it is important to note that autoimmune thyroid disease is extremely common in association with autoimmune Addison’s disease. About 50% of people with autoimmune Addison’s will develop either Graves’ disease or Hashimoto’s thyroiditis. Either one can occur first. In autoimmune Addison’s disease, the destructive autoantibodies usually completely or nearly completely destroy the adrenal cortex cells, leading to a nearly total loss of production of cortisol and aldosterone. In rare cases, there may be a persistence of partial function. In contrast, with autoimmune thyroid disease, there is a wide spectrum of stimulation (in Graves’ disease) or injury (in Hashimoto’s). Most with Graves’ disease need treatment for the hyperthyroidism with antithyroid drugs, radioiodine or surgery, but some will have a spontaneous improvement back to normal or even to hypothyroidism. With Hashimoto’s thyroiditis, the course is highly variable. The typical presentation is thyroid enlargement accompanied by some degree of hypothyroidism, progressing over months or years to the need for full replacement with levothyroxine. The dose is then adjusted with slight increases or decreases over time, using physical signs, symptoms, and TSH level as a guide. However, a significant percentage of people either stabilize at partial replacement (indicating that not all of the thyroid tissue has been injured) or even spontaneously improve back to normal. Even when that happens, one must continue to monitor thyroid function at least annually because there will always be a tendency to progress to further thyroid loss eventually.
Question: Do antidepressants cause salt depletion? Should they be offered to patients with adrenal insufficiency who are suffering from depression? Is there such a thing as salt-depleting medication?
Answer: Many antidepressants can cause low serum sodium. The mechanism is not a depletion of sodium, but an increase in water retention that dilutes the sodium. It has no effect on potassium. It has nothing to do with cortisol metabolism. Since people with adrenal insufficiency have a risk of low sodium if untreated or inadequately treated, it is an appropriate question. However, the actual risk of serious hyponatremia (low sodium) in Addisonians starting antidepressants is low enough that these drugs are not contraindicated. They are very useful for managing depression. The incidence of hyponatremia from these medications is highest in the elderly and those already on diuretics. Addison’s patients should not be on diuretics. When hyponatremia does occur with the use of antidepressants, it appears within the first month and is quickly reversed by stopping the medication. Therefore, I would simply suggest a baseline blood test for sodium and a repeat one month after starting an antidepressant.
Question: I was diagnosed with Addison’s Disease two years ago. I am currently taking hydrocortisone (two 10 mg tablets in the morning and one 10 mg tablet in the evening) along with one 0.1 mg tablet of fludrocortisone in the morning. And, I have type 2 diabetes. For the past 6 months I’ve been on Januvia 50 mg for diabetes. My A1C dropped from 7.7 to 7.3 and is now currently at an A1C of 6.2. My question is what is a safe A1C for my condition? Should I worry about my A1C dropping below 6?
Answer: The management goals of diabetes are the same despite Addison’s disease. A1C of 6.2 is excellent. If it does go even lower, it is OK unless you start to get episodes of hypoglycemia. Insulin therapy is much more likely to cause hypoglycemia than any of the oral medications like Januvia.
Question: I have secondary adrenal insufficiency. In the last three weeks, I have experienced crisis symptoms twice. I was really out of it the one time...was sick for 2.5 weeks...flu, bronchitis and walking pneumonia. I get severe fatigue, confusion, most likely low blood pressure and sugar, extreme weakness but no vomiting or diarrhea. I spread my dosing out more and usually up-dosed the hydrocortisone during the illness but at what point do I need to give IM Solu-Cortef? If Solu-Cortef is used, do I have to go to the ER afterwards?
Answer: IM Solu-Cortef should be used when there is an acute emergency, not to treat chronic or subacute symptoms. If oral steroids work, then there is no need for an injection. If the injection does become necessary as a bridge to prevent shock or loss of consciousness, then immediate care in an emergency department is the next step. With the diagnosis of secondary adrenal insufficiency, always consider coexisting medical issues that may be contributing to the recent symptoms and get medical advice about managing them.
Answer: First, it is important to note that autoimmune thyroid disease is extremely common in association with autoimmune Addison’s disease. About 50% of people with autoimmune Addison’s will develop either Graves’ disease or Hashimoto’s thyroiditis. Either one can occur first. In autoimmune Addison’s disease, the destructive autoantibodies usually completely or nearly completely destroy the adrenal cortex cells, leading to a nearly total loss of production of cortisol and aldosterone. In rare cases, there may be a persistence of partial function. In contrast, with autoimmune thyroid disease, there is a wide spectrum of stimulation (in Graves’ disease) or injury (in Hashimoto’s). Most with Graves’ disease need treatment for the hyperthyroidism with antithyroid drugs, radioiodine or surgery, but some will have a spontaneous improvement back to normal or even to hypothyroidism. With Hashimoto’s thyroiditis, the course is highly variable. The typical presentation is thyroid enlargement accompanied by some degree of hypothyroidism, progressing over months or years to the need for full replacement with levothyroxine. The dose is then adjusted with slight increases or decreases over time, using physical signs, symptoms, and TSH level as a guide. However, a significant percentage of people either stabilize at partial replacement (indicating that not all of the thyroid tissue has been injured) or even spontaneously improve back to normal. Even when that happens, one must continue to monitor thyroid function at least annually because there will always be a tendency to progress to further thyroid loss eventually.
Question: Do antidepressants cause salt depletion? Should they be offered to patients with adrenal insufficiency who are suffering from depression? Is there such a thing as salt-depleting medication?
Answer: Many antidepressants can cause low serum sodium. The mechanism is not a depletion of sodium, but an increase in water retention that dilutes the sodium. It has no effect on potassium. It has nothing to do with cortisol metabolism. Since people with adrenal insufficiency have a risk of low sodium if untreated or inadequately treated, it is an appropriate question. However, the actual risk of serious hyponatremia (low sodium) in Addisonians starting antidepressants is low enough that these drugs are not contraindicated. They are very useful for managing depression. The incidence of hyponatremia from these medications is highest in the elderly and those already on diuretics. Addison’s patients should not be on diuretics. When hyponatremia does occur with the use of antidepressants, it appears within the first month and is quickly reversed by stopping the medication. Therefore, I would simply suggest a baseline blood test for sodium and a repeat one month after starting an antidepressant.
Question: I was diagnosed with Addison’s Disease two years ago. I am currently taking hydrocortisone (two 10 mg tablets in the morning and one 10 mg tablet in the evening) along with one 0.1 mg tablet of fludrocortisone in the morning. And, I have type 2 diabetes. For the past 6 months I’ve been on Januvia 50 mg for diabetes. My A1C dropped from 7.7 to 7.3 and is now currently at an A1C of 6.2. My question is what is a safe A1C for my condition? Should I worry about my A1C dropping below 6?
Answer: The management goals of diabetes are the same despite Addison’s disease. A1C of 6.2 is excellent. If it does go even lower, it is OK unless you start to get episodes of hypoglycemia. Insulin therapy is much more likely to cause hypoglycemia than any of the oral medications like Januvia.
Question: I have secondary adrenal insufficiency. In the last three weeks, I have experienced crisis symptoms twice. I was really out of it the one time...was sick for 2.5 weeks...flu, bronchitis and walking pneumonia. I get severe fatigue, confusion, most likely low blood pressure and sugar, extreme weakness but no vomiting or diarrhea. I spread my dosing out more and usually up-dosed the hydrocortisone during the illness but at what point do I need to give IM Solu-Cortef? If Solu-Cortef is used, do I have to go to the ER afterwards?
Answer: IM Solu-Cortef should be used when there is an acute emergency, not to treat chronic or subacute symptoms. If oral steroids work, then there is no need for an injection. If the injection does become necessary as a bridge to prevent shock or loss of consciousness, then immediate care in an emergency department is the next step. With the diagnosis of secondary adrenal insufficiency, always consider coexisting medical issues that may be contributing to the recent symptoms and get medical advice about managing them.
