Adrenal Support – Fact versus Fiction

The adrenal glands are located above the kidneys: one on the right kidney and one on the left (“ad” meaning “by” and “renal” meaning “related to the kidney”). They are small glands that weigh approximately 7-10 grams each…but don’t be fooled by their small size! They are very important in the production of powerful hormones that help regulate blood pressure, salt and potassium levels, and glucose metabolism. They also help the body adequately respond to stress and are involved in female/ male hormone production.

These glands consist of different areas, with each area secreting different hormones such as glucocorticoids [gloo-koh-kawr-ti-koids] (primarily cortisol) and mineralocorticoids [min-er-uh-loh-kawr-ti-koids] (primarily aldosterone), among others. In this article, we will focus on cortisol and aldosterone, as they are the two most affected in adrenal insufficiency – a disorder involving the lack of these vital hormones.

for the “fight or flight” response, also referred to as a “stress hormone.” Its secretion by the adrenal glands is regulated by the pituitary gland – a master gland located in the middle of the base of the brain that sends out messages to other glands to produce specific hormones. Think of the pituitary as the director of an orchestra: it gives signals to musicians (one of the musicians being the adrenal gland) on when and how long to play certain musical notes (or when and how much hormone to secrete and for how long). The rhythm of the pituitary is elegantly regulated in a pulsating manner, so the levels in blood fluctuate and are not always the same, varying even at different times during the day.

Much popular advice is found in various public sources, such as the internet, regarding the need for “adrenal support.” Not infrequently, cortisol levels may be found to be low, but interpretation is not always straightforward. The need for adrenal hormone support should rely on very specific testing that your medical team will order to establish the diagnosis of adrenal insufficiency and, if present, what type.

Adrenal glands can be affected by diseases that would result in underproduction or complete lack of hormones (in this case cortisol). This can occur through several mechanisms: within the adrenal glands themselves and therefore named primary adrenal insufficiency, or by mechanisms other than within the adrenal gland, for example, secondary to the pituitary gland not sending enough messages to the adrenals (in this case it will be the director of the orchestra who is not telling the adrenals to play, i.e., secrete cortisol). Adrenal insufficiency can also occur in people who took medications for other conditions, such as steroids for rheumatoid arthritis. The last two examples are classified as secondary adrenal insufficiency, because the problem is not inherent to the adrenal gland itself.

The most common cause of primary adrenal insufficiency, accounting for over 90 percent of cases, is the development of antibodies attacking our own tissue, in this case adrenal tissue, resulting in destruction of the adrenals and a lack of not only cortisol but also other hormones produced by it, such as aldosterone [al-doh-sti-rohn].

In secondary adrenal insufficiency, the ability to produce hormones that help salt and water balance (i.e., aldosterone) are not affected, nor is the ability to make female- or male-like hormones. This is because the problem here is not in the adrenal gland itself but in the message. It is important to make clear what type of adrenal insufficiency is present, as this will influence what treatments are needed. To continue the analogy, do we need to treat the director of the orchestra or the musician?

Now let’s focus on primary adrenal insufficiency, or what is also known as Addison’s disease. Symptoms vary depending on the severity and time of lack of adrenal hormones. When it is very severe, the condition can result in an adrenal or Addisonian crisis, which is a life-threatening condition. The table on page 22 details the symptoms of an adrenal crisis.

After testing confirms the diagnosis (usually done through a “stimulation test” with blood samples taken at specific time points before and after a stimulating hormone is given intravenously or intramuscularly), patients usually will be started on adrenal replacement of a corticosteroid [kawr-tuh-koh-ster-oid] (also known as a glucocorticoid). There are many forms of this medicine. Typically a dose should be taken as soon as you awake in the morning. Another, smaller dose is taken later in the day. At times even a third dose might be recommended. You should be well aware that these hormones are necessary for life; however, an excess of them also result in problems. Taking too much routinely can induce weight gain, higher blood pressure, thinning of bones and other undesirable effects, so make sure to discuss in detail with your doctor how to take the medication and how much.

When we are ill, our pituitary gland tells the adrenals to put out more stress hormone (i.e., cortisol) to help deal with illness, thus you will need to increase your corticosteroid dose for at least 1-2 days. Often a doubling of your daily dose is recommended. The dose should be decreased back to the baseline dosage as soon as your illness is improving. If you have any vomiting and are unable to keep your pills down, you must go to an emergency room to have the edication administered intravenously (see Check Points chart on page 22 for additional tips).

ADRENAL CRISIS SYMPTOMS
Fever Abdominal pain
Weakness Confusion
Nausea, vomiting Fainting, collapse, coma
 
Check Points for Patients with Adrenal Insufficiency
1. Know when and how much to increase the dose of your corticosteroid medication.
2. Ensure you always have enough medication with you to double the dose for several days if needed in case of illness.
3. Wear a medical bracelet or necklace that notes you have adrenal insufficiency and are on corticosteroids treatment.
4. Carry an emergency corticosteroid shot with you when traveling.
5. Learn the symptoms of an adrenal crisis (see above) so you know when to seek help.
6. If you are unable to keep down your oral corticosteroid medication secondary to nausea and vomiting, go to the closest ER or call 911.

Surgery is a stress to our bodies. You need to notify your surgeon, anesthesiologist and any doctor caring for you that you have adrenal insufficiency and are taking corticosteroids. They will manage the increased doses that will be required for your body undergoing surgery.

Emergencies happen…and the need for corticosteroid is critical in such situations. You might not be able to tell your caregivers that you have adrenal insufficiency. For that reason, it is highly advisable that at all times you wear an alert bracelet or necklace that states that you are on corticosteroid medication. This can truly be life saving!

Stress can be different from person to person, so discuss with your doctor situations that might require additional corticosteroid. Some people need increased doses for situations such as dental visits, but most do not. Pregnancy is another situation that will require dosage adjustment.

Lastly, in primary adrenal insufficiency, BUT NOT in secondary adrenal insufficiency, other hormone replacements may be necessary in addition to a corticosteroid, namely a mineralocorticoid. Although this is not typically increased from your routine daily prescribed dose, when you are under stress, many physicians advise increasing the dose in hot weather when you will be outdoors for prolonged periods of time and are sweating. Your medical team will help with when and how much to adjust your medication during such times. Many experts also advise that in the case of primary adrenal insufficiency, besides increasing the corticosteroid dose in stress situations, that you also take in salt and water. One way to do this is to eat a small bag of chips and drink at least eight ounces of water with the chips daily (assuming that you are not nauseated or throwing up). If you are unable to keep your oral corticosteroid down, you need to go to the closest emergency room to get help.

It is not always possible to be near an emergency room, particularly when traveling to other parts of the world. Discuss with your doctor whether an injectable form of corticosteroid that is typically given into a muscle might be something you should have with you when you travel. That way you can carry it with you before you leave for a trip and make this a part of your travel planning!

It is also important to take advantage of yearly flu vaccinations and a pneumovax [noo-mow-vax] vaccine to protect against the most common form of pneumonia, as prevention of illness is always better than going through an illness!

So make sure you seek the opinion of an expert in regards to your diagnosis of adrenal insufficiency and the need for adrenal support. Discuss your questions and treatment plan for daily needs as well as travel and emergencies. An endocrinologist is an expert in hormonal diseases and disorders---and a great resource for your medical needs in managing adrenal insufficiency.