NADF News® Q & A – 2018
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, 2018
Question: I carry an EpiPen® because of the extreme reaction I have to bee stings. If I were to be stung by a bee, would I take both the epinephrine and the hydrocortisone?
Answer: The bee sting allergy has the potential to cause an immediate life threatening reaction that is promptly blocked by the EpiPen®. I would suggest adding an extra dose of oral hydrocortisone 10 mg after the epinephrine has a chance to work. An injection of IM or SC hydrocortisone should not be necessary.
Question: What are the effects of chronic ACTH overproduction from a tumor associated with Nelson’s Syndrome, on a person that has had an adrenalectomy?
Answer: People with Nelson’s syndrome have two issues: The overproduction of ACTH is accompanied by excess melanocortin, which causes darkening of the skin. The other issue is that the ACTH producing tumor may grow and cause local anatomical damage in the sella, including compression of the remaining pituitary tissue and compression of the optic nerves. If that happens, surgery or radiation therapy may be needed.
Question: If a person has both thyroid and adrenal issues, do they have to get the adrenal issues solved first?
Answer: They can be handled at the same time, unless there is an adrenal crisis, where the adrenal treatment is an emergency.
Question: I have Addison’s disease, and I’m going in for an MRI soon. I’m getting the procedure to check my heart, with and without contrast. I got anxious the last time I was in an MRI machine, and felt like I needed extra hydrocortisone. Is there any recommended procedure for this?
Answer: Getting an MRI does not cause any physical stress. If there is a severe emotional reaction to the claustrophobia of the study, it is OK to take along an extra 5 mg of hydrocortisone to be given. However, this is really unlikely to be needed.
Question: I suspect I have a pheochromocytoma because of the symptoms I have. But it’s not backed up with labs. I guess a pheo in the head or neck area will not cast catecholamines so you could indeed wind up with a false/negative. Is there a better way/test to find out?
Answer: Pheochromocytomas only occur in the adrenal glands. Catecholamine-secreting tumors outside the adrenals can occur anywhere in the sympathetic nervous system chain, from the neck down to the bladder. These are called paragangliomas. When they produce hormones, they secrete only norepinephrine, not epinephrine. The laboratory work up should show an elevated level of plasma metanephrines and urine metanephrines. If these levels are normal, it is unlikely that a paraganglioma is present. Symptoms alone are not reliable.
Question: I have secondary adrenal insufficiency. My adrenal glands are small and produce cortisol with proper diet and care. Stress will put me into crises. When I go into crises I lose all muscle control so it is a race of time to get me to the ER. I was born with only the right thyroid, and now have nodules on it. I have hypothyroidism and tried Armor and levothyroxine, which I’ve had allergic reactions to. My father had thyroid nodule cancer. If I need to have the right thyroid removed because of cancer, is there medication for me to take for the thyroid that will not damage my adrenal glands?
Answer: There are mistaken concepts about adrenal insufficiency as well as thyroid disease. The simple answer to the question is that thyroid hormone in the form of levothyroxine would be necessary if the remainder of the thyroid is removed. Levothyroxine cannot be allergenic. If allergic symptoms occurred in the past, it was to the inert ingredients in the tablet. One way to avoid that is to use a liquid form of levothyroxine in the brand Tirosint®. Thyroid hormone cannot damage the adrenals.
Question: I was diagnosed with Addison’s disease recently after I had a seizure from hypotension. I am a urologic surgeon and am supposed to return to work. I am worried that the stress of my job (which is unpredictable and variable) will be difficult to manage. I take call regularly and cover 3 hospitals simultaneously while doing so often as long as 7 days straight or more. I worry that the periodic confusion that I experience now (i.e., I walked out of a store and forgot to pay) may limit my ability to always be correct as my job requires. I am wondering if there are other surgeons with the disorder who can confirm that they have been able to continue to work as I do now. I have to worry about not only the lives of my patients but also my life as I am only 40 years old. Any resources that you can help me with would be greatly appreciated. I am even stressed thinking about work right now.
Answer: I certainly understand your concern. I do not have any surgeons with Addison’s disease in my practice at this time, although I do have an emergency room physician who performs very well at his job, plus a few nurses and medical technicians. I think the major challenge you face is the unpredictability of the hours and work stress. You are going to have to learn how to monitor your stress to develop a pattern of glucocorticoid therapy that works for you. Start with “normal” days with normal hours of work, allowing normal meal breaks and rest, and find a dosage of glucocorticoids and mineralocorticoids that keeps you comfortable. Then, by trial and error, find the amount of extra hydrocortisone that you need to add for specific types of extra stresses, such as a prolonged surgery or excessive physical exertion, or later than normal hours. Always carry extra hydrocortisone tablets with you. You will gradually learn how to offset each type of stress with a specific extra dose. It will take time, but it can be done. Don’t give up on your career!
Question: I’ve read in an article that altitude sickness medication is bad for anyone with Addison’s disease, because it interferes with the sodium and potassium balance in the body. Is that true?
Answer: The most common drug used to prevent altitude sickness does alter the kidney metabolism of electrolytes, making it risky in Addison’s disease. If symptoms occur, a slight increase in the dosage of hydrocortisone is helpful.
Answer: The bee sting allergy has the potential to cause an immediate life threatening reaction that is promptly blocked by the EpiPen®. I would suggest adding an extra dose of oral hydrocortisone 10 mg after the epinephrine has a chance to work. An injection of IM or SC hydrocortisone should not be necessary.
Question: What are the effects of chronic ACTH overproduction from a tumor associated with Nelson’s Syndrome, on a person that has had an adrenalectomy?
Answer: People with Nelson’s syndrome have two issues: The overproduction of ACTH is accompanied by excess melanocortin, which causes darkening of the skin. The other issue is that the ACTH producing tumor may grow and cause local anatomical damage in the sella, including compression of the remaining pituitary tissue and compression of the optic nerves. If that happens, surgery or radiation therapy may be needed.
Question: If a person has both thyroid and adrenal issues, do they have to get the adrenal issues solved first?
Answer: They can be handled at the same time, unless there is an adrenal crisis, where the adrenal treatment is an emergency.
Question: I have Addison’s disease, and I’m going in for an MRI soon. I’m getting the procedure to check my heart, with and without contrast. I got anxious the last time I was in an MRI machine, and felt like I needed extra hydrocortisone. Is there any recommended procedure for this?
Answer: Getting an MRI does not cause any physical stress. If there is a severe emotional reaction to the claustrophobia of the study, it is OK to take along an extra 5 mg of hydrocortisone to be given. However, this is really unlikely to be needed.
Question: I suspect I have a pheochromocytoma because of the symptoms I have. But it’s not backed up with labs. I guess a pheo in the head or neck area will not cast catecholamines so you could indeed wind up with a false/negative. Is there a better way/test to find out?
Answer: Pheochromocytomas only occur in the adrenal glands. Catecholamine-secreting tumors outside the adrenals can occur anywhere in the sympathetic nervous system chain, from the neck down to the bladder. These are called paragangliomas. When they produce hormones, they secrete only norepinephrine, not epinephrine. The laboratory work up should show an elevated level of plasma metanephrines and urine metanephrines. If these levels are normal, it is unlikely that a paraganglioma is present. Symptoms alone are not reliable.
Question: I have secondary adrenal insufficiency. My adrenal glands are small and produce cortisol with proper diet and care. Stress will put me into crises. When I go into crises I lose all muscle control so it is a race of time to get me to the ER. I was born with only the right thyroid, and now have nodules on it. I have hypothyroidism and tried Armor and levothyroxine, which I’ve had allergic reactions to. My father had thyroid nodule cancer. If I need to have the right thyroid removed because of cancer, is there medication for me to take for the thyroid that will not damage my adrenal glands?
Answer: There are mistaken concepts about adrenal insufficiency as well as thyroid disease. The simple answer to the question is that thyroid hormone in the form of levothyroxine would be necessary if the remainder of the thyroid is removed. Levothyroxine cannot be allergenic. If allergic symptoms occurred in the past, it was to the inert ingredients in the tablet. One way to avoid that is to use a liquid form of levothyroxine in the brand Tirosint®. Thyroid hormone cannot damage the adrenals.
Question: I was diagnosed with Addison’s disease recently after I had a seizure from hypotension. I am a urologic surgeon and am supposed to return to work. I am worried that the stress of my job (which is unpredictable and variable) will be difficult to manage. I take call regularly and cover 3 hospitals simultaneously while doing so often as long as 7 days straight or more. I worry that the periodic confusion that I experience now (i.e., I walked out of a store and forgot to pay) may limit my ability to always be correct as my job requires. I am wondering if there are other surgeons with the disorder who can confirm that they have been able to continue to work as I do now. I have to worry about not only the lives of my patients but also my life as I am only 40 years old. Any resources that you can help me with would be greatly appreciated. I am even stressed thinking about work right now.
Answer: I certainly understand your concern. I do not have any surgeons with Addison’s disease in my practice at this time, although I do have an emergency room physician who performs very well at his job, plus a few nurses and medical technicians. I think the major challenge you face is the unpredictability of the hours and work stress. You are going to have to learn how to monitor your stress to develop a pattern of glucocorticoid therapy that works for you. Start with “normal” days with normal hours of work, allowing normal meal breaks and rest, and find a dosage of glucocorticoids and mineralocorticoids that keeps you comfortable. Then, by trial and error, find the amount of extra hydrocortisone that you need to add for specific types of extra stresses, such as a prolonged surgery or excessive physical exertion, or later than normal hours. Always carry extra hydrocortisone tablets with you. You will gradually learn how to offset each type of stress with a specific extra dose. It will take time, but it can be done. Don’t give up on your career!
Question: I’ve read in an article that altitude sickness medication is bad for anyone with Addison’s disease, because it interferes with the sodium and potassium balance in the body. Is that true?
Answer: The most common drug used to prevent altitude sickness does alter the kidney metabolism of electrolytes, making it risky in Addison’s disease. If symptoms occur, a slight increase in the dosage of hydrocortisone is helpful.
Q&A from June, 2018
Question: Can I take my thyroid hormone replacement meds and hydrocortisone at the same time, like first thing in the morning?
Answer: Yes, they can be taken together. However, vitamins, calcium, iron, antacids and food should be taken at least half an hour after thyroid hormone to avoid changes in absorption.
Question: I was wondering about non-classical CAH, and if the level of androstenedione can decrease with age from year 22 to 27 years old and still be non-classical CAH? The test of androstenedione was not normal at 22 years of age, slightly elevated during use of Diane 35 but then reduced to normal level 5 years later and during use of Yasmin birth control pill.
Answer: Androstenedione levels can diminish over time in non-classic CAH. However, the course in this individual is not what is expected. Cyproterone, the active anti androgen in Diane would normally cause a significant drop, and Yasmin would produce a lesser drop.
Question: I have Addison’s disease, and I’m going to Southeast Asia on a trip. I need to get vaccination shots for typhoid, hepatitis A, and TD. Normally, people get those vaccinations all at once for something like this, but because of my Addison’s do I need to spread them out over time? Can my steroid medication interact badly with the vaccinations or make them less potent, and should I take more if I have a reaction to any of the vaccinations?
Answer: All of these vaccinations are safe and can be given together just like anyone without Addison’s disease. The replacement steroid doses given for Addison’s disease have no effect on the response to the vaccinations. If a reaction does occur, the steroid dose should be increased depending on the severity of the reaction. Mild arm soreness does not need to be treated, but a fever should be treated with Tylenol and an extra 10 mg of hydrocortisone.
Answer: Yes, they can be taken together. However, vitamins, calcium, iron, antacids and food should be taken at least half an hour after thyroid hormone to avoid changes in absorption.
Question: I was wondering about non-classical CAH, and if the level of androstenedione can decrease with age from year 22 to 27 years old and still be non-classical CAH? The test of androstenedione was not normal at 22 years of age, slightly elevated during use of Diane 35 but then reduced to normal level 5 years later and during use of Yasmin birth control pill.
Answer: Androstenedione levels can diminish over time in non-classic CAH. However, the course in this individual is not what is expected. Cyproterone, the active anti androgen in Diane would normally cause a significant drop, and Yasmin would produce a lesser drop.
Question: I have Addison’s disease, and I’m going to Southeast Asia on a trip. I need to get vaccination shots for typhoid, hepatitis A, and TD. Normally, people get those vaccinations all at once for something like this, but because of my Addison’s do I need to spread them out over time? Can my steroid medication interact badly with the vaccinations or make them less potent, and should I take more if I have a reaction to any of the vaccinations?
Answer: All of these vaccinations are safe and can be given together just like anyone without Addison’s disease. The replacement steroid doses given for Addison’s disease have no effect on the response to the vaccinations. If a reaction does occur, the steroid dose should be increased depending on the severity of the reaction. Mild arm soreness does not need to be treated, but a fever should be treated with Tylenol and an extra 10 mg of hydrocortisone.
Q&A from September, 2018
Question: I’ve been struggling getting a diagnosis from my doctors. I have many symptoms of Addison’s disease, but my doctors say it’s unnecessary to run a cortisol test because my sodium and potassium levels are normal. Is that a good indicator for healthy cortisol levels?
Answer: I am disappointed to hear that your doctors refuse to consider Addison’s disease in a person with normal sodium and potassium. These levels do not need to be abnormal to consider the diagnosis. They are most likely to be abnormal during an illness or an adrenal crisis. However, a person with Addison’s disease may be barely compensated in handling electrolytes, but still have significant signs and symptoms of adrenal insufficiency. If the history and physical exam show any suggestive signs of adrenal insufficiency, a prompt work up is essential and potentially lifesaving.
Question: As an Addisonian, I do not intentionally avoid potassium. If I want to eat or drink something with potassium in it, I do it. But I would never take potassium supplements. Should I be avoiding potassium completely?
Answer: There is no need to totally avoid potassium. If the dosages of hydrocortisone and fludrocortisone are adequate, potassium levels will stay normal. I agree that potassium supplements should be avoided.
Question: How does pregnenolone affects those with AI? I ran into some interesting information by accident while researching something unrelated on this hormone, and while it appears it may be the same 17-OH that’s run to check for CAH and I can see its place in the HPA axis, it also appears to be something that may be low in pretty much all of us with AI. When I looked into what could be done about it, the treatments were controversial at best and for the most part not recommended. Is low pregnenolone a problem for adrenally-insufficient patients?
Answer: Unfortunately, pregnenolone has been the subject of much hype in the alternative medicine world, leading to a lot of confusion. It is a steroid made from cholesterol and is a precursor to other steroid hormones including androgens. It is made in the adrenal gland, but also in the gonads and in the brain, where it acts as a neurosteroid, protecting certain neuronal function. In Addison’s disease the adrenals are destroyed, so the adrenal production of pregnenolone is gone. However, the gonadal and brain production are intact. Oral supplements of pregnenolone have been available for many years. They have been promoted as beneficial for all sorts of things, including energy, anti-aging, anti-dementia and improved sexual function. There is no good science proving any benefit at all. It obviously cannot help people with Addison’s disease because there are no adrenal glands. Since we replace cortisol for the Addison’s, there is no need to consider pregnenolone in managing adrenal insufficiency.
Question: I had a bilateral adrenalectomy in 2015 following a MEN2a and bilateral pheochromocytoma diagnosis. My current endocrinologist agreed to let me try using a continuous subcutaneous hydrocortisone infusion (CSHI) pump to see if it improves my quality of life and overall health, and I started using it about a month ago. My doctor isn’t sure of the value of cortisol blood testing to determine optimal basal rates for my pump, but I want to use the results to ensure that I’m not having under or over-replacement. I have some research, specifically from the U.K., which supports testing but my doctor isn’t even sure what tests to order, how to do the testing, or which tests to run. I wondered if Dr. Margulies has any advice or thoughts on using cortisol blood tests to determine absorption and clearance rates to tailor dosing (oral or via a pump) and why it’s not something endocrinologists in the United States seem open to discussing. Can he respond with his thoughts on either a 24 hour cortisol profile or day curve analysis?
Answer: I have no experience with the pump management of adrenal insufficiency or CAH. I always refer people to the UK group. I suggest that the endocrinologist communicate with the UK group for advice. The reason there is no US data is that no one has set up a clinic with the expensive infrastructure necessary to have a pump program here. It is impossible for a private practice to have the backup resources to maintain several patients on the pump.
Question: I have serious concerns about the distinction between a primary and secondary adrenal insufficiency diagnosis. My daughter had negative results from an ACTH stimulation test, and the endocrinologist said she was both primary and secondary. I challenged him to the cause of primary and he could not answer it. We sent her to a clinic, and they said she could get off steroids, and long story short, she is 10 years steroid free. I just don’t understand how so many people are claiming to be primary with this type of testing. Isn’t there a clearer, more definite distinction in diagnosis of primary versus secondary adrenal insufficiency?
Answer: I totally agree that this is a problem. Many people with adrenal insufficiency are mislabeled. Ideally, primary adrenal insufficiency will be confirmed with an elevated morning ACTH, low serum cortisol and a lack of response to Cortrosyn. A positive anti 21-OH adrenal antibody test is very helpful in confirming autoimmune Addison’s disease. Just having an abnormal response to Cortrosyn is not enough for the diagnosis.
Question: I am 73 years old and was diagnosed with Addison’s disease in 2008. Most of this time has been uneventful, as long as I take my medication. Over the past several years, I occasionally have had the sensation of tingling and weakness in my hands, feet and lower legs. It has been happening on a regular basis for the past 2 months, and I am getting concerned.
Answer: The tingling in hands and feet are not directly related to the Addison’s disease. I suggest further evaluation with your doctor. Among the things to look for would be diabetes and low vitamin B 12.
Answer: I am disappointed to hear that your doctors refuse to consider Addison’s disease in a person with normal sodium and potassium. These levels do not need to be abnormal to consider the diagnosis. They are most likely to be abnormal during an illness or an adrenal crisis. However, a person with Addison’s disease may be barely compensated in handling electrolytes, but still have significant signs and symptoms of adrenal insufficiency. If the history and physical exam show any suggestive signs of adrenal insufficiency, a prompt work up is essential and potentially lifesaving.
Question: As an Addisonian, I do not intentionally avoid potassium. If I want to eat or drink something with potassium in it, I do it. But I would never take potassium supplements. Should I be avoiding potassium completely?
Answer: There is no need to totally avoid potassium. If the dosages of hydrocortisone and fludrocortisone are adequate, potassium levels will stay normal. I agree that potassium supplements should be avoided.
Question: How does pregnenolone affects those with AI? I ran into some interesting information by accident while researching something unrelated on this hormone, and while it appears it may be the same 17-OH that’s run to check for CAH and I can see its place in the HPA axis, it also appears to be something that may be low in pretty much all of us with AI. When I looked into what could be done about it, the treatments were controversial at best and for the most part not recommended. Is low pregnenolone a problem for adrenally-insufficient patients?
Answer: Unfortunately, pregnenolone has been the subject of much hype in the alternative medicine world, leading to a lot of confusion. It is a steroid made from cholesterol and is a precursor to other steroid hormones including androgens. It is made in the adrenal gland, but also in the gonads and in the brain, where it acts as a neurosteroid, protecting certain neuronal function. In Addison’s disease the adrenals are destroyed, so the adrenal production of pregnenolone is gone. However, the gonadal and brain production are intact. Oral supplements of pregnenolone have been available for many years. They have been promoted as beneficial for all sorts of things, including energy, anti-aging, anti-dementia and improved sexual function. There is no good science proving any benefit at all. It obviously cannot help people with Addison’s disease because there are no adrenal glands. Since we replace cortisol for the Addison’s, there is no need to consider pregnenolone in managing adrenal insufficiency.
Question: I had a bilateral adrenalectomy in 2015 following a MEN2a and bilateral pheochromocytoma diagnosis. My current endocrinologist agreed to let me try using a continuous subcutaneous hydrocortisone infusion (CSHI) pump to see if it improves my quality of life and overall health, and I started using it about a month ago. My doctor isn’t sure of the value of cortisol blood testing to determine optimal basal rates for my pump, but I want to use the results to ensure that I’m not having under or over-replacement. I have some research, specifically from the U.K., which supports testing but my doctor isn’t even sure what tests to order, how to do the testing, or which tests to run. I wondered if Dr. Margulies has any advice or thoughts on using cortisol blood tests to determine absorption and clearance rates to tailor dosing (oral or via a pump) and why it’s not something endocrinologists in the United States seem open to discussing. Can he respond with his thoughts on either a 24 hour cortisol profile or day curve analysis?
Answer: I have no experience with the pump management of adrenal insufficiency or CAH. I always refer people to the UK group. I suggest that the endocrinologist communicate with the UK group for advice. The reason there is no US data is that no one has set up a clinic with the expensive infrastructure necessary to have a pump program here. It is impossible for a private practice to have the backup resources to maintain several patients on the pump.
Question: I have serious concerns about the distinction between a primary and secondary adrenal insufficiency diagnosis. My daughter had negative results from an ACTH stimulation test, and the endocrinologist said she was both primary and secondary. I challenged him to the cause of primary and he could not answer it. We sent her to a clinic, and they said she could get off steroids, and long story short, she is 10 years steroid free. I just don’t understand how so many people are claiming to be primary with this type of testing. Isn’t there a clearer, more definite distinction in diagnosis of primary versus secondary adrenal insufficiency?
Answer: I totally agree that this is a problem. Many people with adrenal insufficiency are mislabeled. Ideally, primary adrenal insufficiency will be confirmed with an elevated morning ACTH, low serum cortisol and a lack of response to Cortrosyn. A positive anti 21-OH adrenal antibody test is very helpful in confirming autoimmune Addison’s disease. Just having an abnormal response to Cortrosyn is not enough for the diagnosis.
Question: I am 73 years old and was diagnosed with Addison’s disease in 2008. Most of this time has been uneventful, as long as I take my medication. Over the past several years, I occasionally have had the sensation of tingling and weakness in my hands, feet and lower legs. It has been happening on a regular basis for the past 2 months, and I am getting concerned.
Answer: The tingling in hands and feet are not directly related to the Addison’s disease. I suggest further evaluation with your doctor. Among the things to look for would be diabetes and low vitamin B 12.
Q&A from December, 2018
Question: I have a question for you about your thoughts on chronic urticaria and autoimmune thyroid disease. I personally have gotten hives from various ingested items since I was 18 years old. My triggers, the best I can figure, are salicylic acid, tetrazine (yellow #5 food dye), and sulfites. Since I have figured out the sensitivities, I just assumed I was just physically sensitive to stuff. (Talcum powder makes my eyes twitch.) I found on the internet that they are connecting autoimmune thyroid disease with chronic urticaria. I am suspicious about that connection. What are your thoughts?
Answer: There can be a connection between chronic urticaria and autoimmune thyroid disease, especially Hashimoto’s thyroiditis. In most cases, the dermatologic symptoms appear or are worsened when thyroid function is abnormal – either too high or too low. Adjusting the thyroid hormone dosage can improve the situation, but does not necessarily make it resolve. I also often recommend using a hypoallergenic form of thyroid hormone, such as Tirosint, which is a gel cap with no solid ingredients. Even with these strategies, it is usually necessary to use antihistamines, and sometimes a temporary course of high dose glucocorticoids.
Question: I’m a 47-year-old man. I have congenital adrenal hyperplasia. I have also pancreatitis. Can my medication of hydrocortisone affect the lack of pain I feel? Could the pain be masked?
Answer: Replacement glucocorticoids will have no effect on pain. High doses may have an anti-inflammatory effect, but should not diminish your awareness of any activity of the pancreatitis.
Question: I am a 63-year-old female with SAI for 15 years. I developed it from being given high doses of steroids for sudden onset severe adult asthma, off and on for over a year. When diagnosed with SAI, I tried so hard to be weaned off the Prednisone without success. I just saw the pulmonologist as I was having shortness of breath, and he did an inspiratory/expiratory breathing test; it showed my inspiratory muscles were only working at 50%. He felt this was due to steroid myopathy. Have you heard of this and is it reversible? He also did a chest x-ray which was normal and a 6 minute oxygen test which was also normal.
Answer: Steroid myopathy from long term use of high dose glucocorticoids primarily affects the proximal muscles of the arms and legs, but can cause weakness in any muscles. Chronic obstructive lung disease itself does weaken the respiratory muscles and the steroid use may be contributing as well. Unfortunately, the treatment from the pulmonary specialist may require continued use of steroids. If they can be weaned, whatever contribution to the shortness of breath that may be due to the myopathy may improve. There is no other specific treatment to improve the muscle tone.
Question: I have primary adrenal insufficiency. I’ve also been having issues with acidosis and bicarbonate drops quickly at times. I take potassium citrate. I was previously on sodium bicarbonate, but it didn’t seem effective. Maybe the potassium is part of the problem? I see a nephrologist who is focused on treating, but not diagnosing the problem.
Answer: The presence of acidosis suggests a primary renal disorder. Adding potassium is tricky because of the primary adrenal insufficiency. I would defer to the nephrologist who should have an understanding of the mechanism of the acidosis. If there is uncertainty about the cause, perhaps another nephrology opinion would be warranted.
Answer: There can be a connection between chronic urticaria and autoimmune thyroid disease, especially Hashimoto’s thyroiditis. In most cases, the dermatologic symptoms appear or are worsened when thyroid function is abnormal – either too high or too low. Adjusting the thyroid hormone dosage can improve the situation, but does not necessarily make it resolve. I also often recommend using a hypoallergenic form of thyroid hormone, such as Tirosint, which is a gel cap with no solid ingredients. Even with these strategies, it is usually necessary to use antihistamines, and sometimes a temporary course of high dose glucocorticoids.
Question: I’m a 47-year-old man. I have congenital adrenal hyperplasia. I have also pancreatitis. Can my medication of hydrocortisone affect the lack of pain I feel? Could the pain be masked?
Answer: Replacement glucocorticoids will have no effect on pain. High doses may have an anti-inflammatory effect, but should not diminish your awareness of any activity of the pancreatitis.
Question: I am a 63-year-old female with SAI for 15 years. I developed it from being given high doses of steroids for sudden onset severe adult asthma, off and on for over a year. When diagnosed with SAI, I tried so hard to be weaned off the Prednisone without success. I just saw the pulmonologist as I was having shortness of breath, and he did an inspiratory/expiratory breathing test; it showed my inspiratory muscles were only working at 50%. He felt this was due to steroid myopathy. Have you heard of this and is it reversible? He also did a chest x-ray which was normal and a 6 minute oxygen test which was also normal.
Answer: Steroid myopathy from long term use of high dose glucocorticoids primarily affects the proximal muscles of the arms and legs, but can cause weakness in any muscles. Chronic obstructive lung disease itself does weaken the respiratory muscles and the steroid use may be contributing as well. Unfortunately, the treatment from the pulmonary specialist may require continued use of steroids. If they can be weaned, whatever contribution to the shortness of breath that may be due to the myopathy may improve. There is no other specific treatment to improve the muscle tone.
Question: I have primary adrenal insufficiency. I’ve also been having issues with acidosis and bicarbonate drops quickly at times. I take potassium citrate. I was previously on sodium bicarbonate, but it didn’t seem effective. Maybe the potassium is part of the problem? I see a nephrologist who is focused on treating, but not diagnosing the problem.
Answer: The presence of acidosis suggests a primary renal disorder. Adding potassium is tricky because of the primary adrenal insufficiency. I would defer to the nephrologist who should have an understanding of the mechanism of the acidosis. If there is uncertainty about the cause, perhaps another nephrology opinion would be warranted.
