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 March 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.
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: 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.
Q&A from June 2025
Question: What temperature does my Solu-Cortef need to be kept at? I’m traveling to warmer climates and want to make sure my medication remains stable.
Answer: Solu-Cortef should be stored at room temperature: 68 to 77 degrees Fahrenheit. Once reconstituted, it should be administered immediately. You should keep it from ever getting above 86 degrees.
Question: My creatinine levels are above normal at 1.18 and have been running above 1.0 for years. Now the doctors are throwing around “chronic kidney disease”. What is the relationship between these levels and Addison’s? Is it something most of us with primary Adrenal insufficiency have?
Answer: Creatinine levels reflect kidney function. There are slight variations in the normal range at different labs, but a typical sample normal range is 0.60 - 1.30 for males, 0.50 - 1.00 for females. When there is a persistent elevation, doctors will label it as chronic kidney disease, but that does not necessarily mean it will progress and become severe enough to require treatment like dialysis. In addition to monitoring creatinine, tests for BUN (blood urea nitrogen) and GFR (glomerular filtration rate) should be followed. It is common to find a single elevated test due to a recent illness, especially if it led to dehydration, or the test is performed after a prolonged interval without fluid intake. Addison’s disease does not directly cause kidney injury. If there is a progressive worsening of kidney function, a consultation with a nephrologist (kidney specialist) is necessary.
Question: How do our electrolytes play with Addison’s? Should I supplement my diet with something like Liquid IV regularly? I think when I had a crisis (some years ago now) it was due to my electrolytes being out of whack after I had been throwing up with flu. I became unconscious. How does taking something like Liquid IV affect our Addison’s?
Answer: Electrolyte (sodium and potassium) abnormalities are cardinal features of Addison’s disease. When undiagnosed or poorly treated, especially during an acute illness, Addison’s will lead to an elevated potassium and a lower sodium. Oral electrolyte solutions are not needed in managing adrenal insufficiency. The treatment is proper doses of hydrocortisone and fludrocortisone plus normal hydration with water.
Question: I’m 80 years old, was diagnosed with Addison’s in 2017 and have since have developed osteoporosis. My doctor would like to give a Reclast Infusion of zoledronic acid to treat the osteo, however I’m very nervous about the side effects and or impact it may have. Do you have any insight or perspective on this treatment for Osteo with AI?
Answer: Zoledronic acid is a well-established treatment for osteoporosis. It is a bisphosphonate, like alendronate and risedronate, but it is given by IV infusion once a year, so it has none of the GI side effects of the oral medications. The one important side effect, most often seen with the first infusion, can be flu-like syndrome that can last 24 to 48 hours. Despite that possibility, it is safe and definitely effective for people with adrenal insufficiency. If achiness or fever do occur, one can treat it with acetaminophen and a temporary mild stress dose of hydrocortisone.
Answer: Solu-Cortef should be stored at room temperature: 68 to 77 degrees Fahrenheit. Once reconstituted, it should be administered immediately. You should keep it from ever getting above 86 degrees.
Question: My creatinine levels are above normal at 1.18 and have been running above 1.0 for years. Now the doctors are throwing around “chronic kidney disease”. What is the relationship between these levels and Addison’s? Is it something most of us with primary Adrenal insufficiency have?
Answer: Creatinine levels reflect kidney function. There are slight variations in the normal range at different labs, but a typical sample normal range is 0.60 - 1.30 for males, 0.50 - 1.00 for females. When there is a persistent elevation, doctors will label it as chronic kidney disease, but that does not necessarily mean it will progress and become severe enough to require treatment like dialysis. In addition to monitoring creatinine, tests for BUN (blood urea nitrogen) and GFR (glomerular filtration rate) should be followed. It is common to find a single elevated test due to a recent illness, especially if it led to dehydration, or the test is performed after a prolonged interval without fluid intake. Addison’s disease does not directly cause kidney injury. If there is a progressive worsening of kidney function, a consultation with a nephrologist (kidney specialist) is necessary.
Question: How do our electrolytes play with Addison’s? Should I supplement my diet with something like Liquid IV regularly? I think when I had a crisis (some years ago now) it was due to my electrolytes being out of whack after I had been throwing up with flu. I became unconscious. How does taking something like Liquid IV affect our Addison’s?
Answer: Electrolyte (sodium and potassium) abnormalities are cardinal features of Addison’s disease. When undiagnosed or poorly treated, especially during an acute illness, Addison’s will lead to an elevated potassium and a lower sodium. Oral electrolyte solutions are not needed in managing adrenal insufficiency. The treatment is proper doses of hydrocortisone and fludrocortisone plus normal hydration with water.
Question: I’m 80 years old, was diagnosed with Addison’s in 2017 and have since have developed osteoporosis. My doctor would like to give a Reclast Infusion of zoledronic acid to treat the osteo, however I’m very nervous about the side effects and or impact it may have. Do you have any insight or perspective on this treatment for Osteo with AI?
Answer: Zoledronic acid is a well-established treatment for osteoporosis. It is a bisphosphonate, like alendronate and risedronate, but it is given by IV infusion once a year, so it has none of the GI side effects of the oral medications. The one important side effect, most often seen with the first infusion, can be flu-like syndrome that can last 24 to 48 hours. Despite that possibility, it is safe and definitely effective for people with adrenal insufficiency. If achiness or fever do occur, one can treat it with acetaminophen and a temporary mild stress dose of hydrocortisone.
Q&A from September 2025
Question: Is it okay to take marshmallow root with Adrenal Insufficiency?
Answer: The only concern about marshmallow root is the tendency for the oral form to delay absorption of other medications. Therefore, there may be a need to separate it from oral glucocorticoids and other meds.
Question: Is Bladder Ease harmful for those of us with Adrenal Insufficiency? My Uro-Gyn doctor recommended some supplements. There was one more a product called Javacid which contained “diglycerides licorice”. I know ashwagandha can be dangerous as it lowers cortisol, but was unsure of some of these other supplements.
Answer: The ingredients in this over-the-counter supplement have an anticholinergic effect - they may soothe bladder muscle tone, but will tend to cause dry mouth, dry eyes and constipation. There is also potential to cause changes in blood pressure, heart rate and irregular heartbeat. I would caution anyone with adrenal insufficiency to ask their individual doctor concerning the specific risks of any of these side effects.
Question: I just received my renin blood test which is abnormal at 7.52. I have a colonoscopy coming up and want to know what to do before then to help with these blood results.
Answer: Renin levels are helpful in evaluating the adequacy of mineralocorticoid (fludrocortisone) replacement in Addison's disease. An elevated level indicates relatively low blood volume. An increase in sodium intake or an increase in fludrocortisone dosage would work. I suggest that you speak to your endocrinologist about your specific regimen.
Question: A few toes on one foot have been very painful on and off, and my endocrinologist told me it was due to Addison's disease. Is this correct?
Answer: Addison’s does not directly cause neuropathy. The indirect links include diabetes and pernicious anemia.
Question: I have had primary adrenal insufficiency since 1978. I just found out I have arthritis. The pain is from my hip all the way down to my foot. Can this cause more stress? It’s very painful. How do I compensate with hydrocortisone, or do I need to?
Answer: Arthritis, whether typical osteoarthritis or the various forms of autoimmune arthritis, such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and lupus, can cause significant pain and inflammation. Pain is a stressor, so individuals with adrenal insufficiency may need to adjust their steroid regimen to help deal with it. The preferred approach is to utilize therapies that may diminish the inflammation and pain produced by the disorder. If there is less pain and inflammation, there will be less of a need to supplement with steroids. There is no simple formula for the steroid dose for pain. If anti-inflammatory therapies and analgesics are inadequate, try adding a very low dose of hydrocortisone when needed, but try to resume your usual dosage if the pain subsides.
Question: Have there been any studies that suggest any links to taking steroids for long periods leading to bipolar and mood disorder? I’m wondering if there is any awareness towards this since the primary control of Addison's is with steroids.
Answer: The cause of bipolar disorder is uncertain. There is no evidence that maintenance doses of glucocorticoids to treat adrenal insufficiency cause it. However, high doses typically used to treat other diseases can have dramatic effects on mood, including acute psychosis, and inadequate glucocorticoid replacement can contribute to anxiety and depression.
Question: I have no family history of anyone with Addison's disease. Is it possible that I acquired Addison's due to developments during puberty?
Answer: Most people with Addison's disease have an autoimmune injury to the adrenal glands. There is a link to other autoimmune endocrine diseases that have a similar pattern of injury, especially the autoimmune thyroid diseases Hashimoto's thyroiditis and Graves' disease. Other linked diseases include type 1 diabetes, pernicious anemia, hypoparathyroidism, premature gonadal failure and vitiligo. A lack of family history of Addison's disease itself is actually typical, but it is very common for one or more of the other disorders to appear in family members.
Question: If a patient with Adrenal Insufficiency needs to take a methylprednisolone dose pack for another medical reason (I.e. migraine taper or lung issue) and it is unavoidable. Should they stop their replacement dosage while they take the additional steroid of the taper? Or should they take their replacement dosage with the steroid of the steroid dose pack?
Answer: Since the course of steroid therapy provided by the dose pack is intended to give an acute surge above the baseline level, I usually recommend continuation of the normal maintenance dose during and after the days on the dose pack. Reducing the maintenance dose would diminish the clinical benefit of the extra steroids.
Answer: The only concern about marshmallow root is the tendency for the oral form to delay absorption of other medications. Therefore, there may be a need to separate it from oral glucocorticoids and other meds.
Question: Is Bladder Ease harmful for those of us with Adrenal Insufficiency? My Uro-Gyn doctor recommended some supplements. There was one more a product called Javacid which contained “diglycerides licorice”. I know ashwagandha can be dangerous as it lowers cortisol, but was unsure of some of these other supplements.
Answer: The ingredients in this over-the-counter supplement have an anticholinergic effect - they may soothe bladder muscle tone, but will tend to cause dry mouth, dry eyes and constipation. There is also potential to cause changes in blood pressure, heart rate and irregular heartbeat. I would caution anyone with adrenal insufficiency to ask their individual doctor concerning the specific risks of any of these side effects.
Question: I just received my renin blood test which is abnormal at 7.52. I have a colonoscopy coming up and want to know what to do before then to help with these blood results.
Answer: Renin levels are helpful in evaluating the adequacy of mineralocorticoid (fludrocortisone) replacement in Addison's disease. An elevated level indicates relatively low blood volume. An increase in sodium intake or an increase in fludrocortisone dosage would work. I suggest that you speak to your endocrinologist about your specific regimen.
Question: A few toes on one foot have been very painful on and off, and my endocrinologist told me it was due to Addison's disease. Is this correct?
Answer: Addison’s does not directly cause neuropathy. The indirect links include diabetes and pernicious anemia.
Question: I have had primary adrenal insufficiency since 1978. I just found out I have arthritis. The pain is from my hip all the way down to my foot. Can this cause more stress? It’s very painful. How do I compensate with hydrocortisone, or do I need to?
Answer: Arthritis, whether typical osteoarthritis or the various forms of autoimmune arthritis, such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and lupus, can cause significant pain and inflammation. Pain is a stressor, so individuals with adrenal insufficiency may need to adjust their steroid regimen to help deal with it. The preferred approach is to utilize therapies that may diminish the inflammation and pain produced by the disorder. If there is less pain and inflammation, there will be less of a need to supplement with steroids. There is no simple formula for the steroid dose for pain. If anti-inflammatory therapies and analgesics are inadequate, try adding a very low dose of hydrocortisone when needed, but try to resume your usual dosage if the pain subsides.
Question: Have there been any studies that suggest any links to taking steroids for long periods leading to bipolar and mood disorder? I’m wondering if there is any awareness towards this since the primary control of Addison's is with steroids.
Answer: The cause of bipolar disorder is uncertain. There is no evidence that maintenance doses of glucocorticoids to treat adrenal insufficiency cause it. However, high doses typically used to treat other diseases can have dramatic effects on mood, including acute psychosis, and inadequate glucocorticoid replacement can contribute to anxiety and depression.
Question: I have no family history of anyone with Addison's disease. Is it possible that I acquired Addison's due to developments during puberty?
Answer: Most people with Addison's disease have an autoimmune injury to the adrenal glands. There is a link to other autoimmune endocrine diseases that have a similar pattern of injury, especially the autoimmune thyroid diseases Hashimoto's thyroiditis and Graves' disease. Other linked diseases include type 1 diabetes, pernicious anemia, hypoparathyroidism, premature gonadal failure and vitiligo. A lack of family history of Addison's disease itself is actually typical, but it is very common for one or more of the other disorders to appear in family members.
Question: If a patient with Adrenal Insufficiency needs to take a methylprednisolone dose pack for another medical reason (I.e. migraine taper or lung issue) and it is unavoidable. Should they stop their replacement dosage while they take the additional steroid of the taper? Or should they take their replacement dosage with the steroid of the steroid dose pack?
Answer: Since the course of steroid therapy provided by the dose pack is intended to give an acute surge above the baseline level, I usually recommend continuation of the normal maintenance dose during and after the days on the dose pack. Reducing the maintenance dose would diminish the clinical benefit of the extra steroids.
