Addison’s disease, also known as primary adrenal insufficiency, is a disorder that occurs when the adrenal glands do not produce enough cortisol and aldosterone. This can be caused by damage to the adrenal glands themselves or by issues with the pituitary gland in the brain, which helps regulate adrenal function. There are a number of factors that can exacerbate symptoms of Addison’s disease and cause adrenal crises, which require urgent medical treatment. Knowing what makes the condition worse can help Addison’s patients manage it appropriately.
Stress
Stress is one of the major triggers that can worsen Addison’s disease symptoms. Stress causes the body to release hormones like cortisol and epinephrine. For people with Addison’s disease who already have low cortisol levels, excess stress can rapidly deplete cortisol reserves and precipitate an adrenal crisis. Things that can contribute to physical or emotional stress and negatively impact adrenal function include:
– Infections
– Surgery or medical procedures
– Trauma or injury
– Emotional stressors like grieving, relationship issues, work problems
– Low blood sugar episodes
– Dehydration
– Extreme sports or exercise
During times of stress, people with Addison’s disease may need to temporarily increase their corticosteroid dosage to provide extra cortisol coverage. Working to manage and reduce stress through lifestyle modifications can also help minimize its impact.
Infections
Infections put significant stress on the body and adrenal glands. Even relatively minor infections can cause deterioration in people with Addison’s disease. Some of the infections that pose high risk include:
– Flu
– COVID-19
– Bronchitis
– Pneumonia
– Sinus infections
– Urinary tract infections
– Gastroenteritis
– Candida infections
Bacterial infections tend to be more adrenal-taxing than viral infections. Fever from any infection can also speed up metabolism and cortisol processing, depleting reserves. Infections should be reported to a doctor immediately so they can determine if a temporary increase in corticosteroid medication is warranted. Prompt antibiotic treatment can help shorten the duration.
Injuries and Trauma
Physical injuries, wounds, surgeries and major trauma are very challenging for the adrenal-insufficient body to handle. Things like car accidents, burns, broken bones, or procedures like open heart surgery can all severely test the adrenals. Without enough cortisol reserves, the body may struggle to cope with the magnitude of stress this puts on the body.
Doctors treating any significant injury or performing major surgery will administer corticosteroids, often by IV, while monitoring the patient closely for signs of adrenal crisis. Speedy recovery depends on providing supplemental cortisol to handle the demands. Lingering pain, risk of infection, and other complications mean the body remains under high adrenal demand during recuperation.
Gastrointestinal Issues
Nausea, vomiting and diarrhea can have rapid impacts on people with Addison’s disease. The GI disturbances make it hard to keep oral medications down and can lead to dangerous dehydration as fluid volumes deplete. The act of vomiting also triggers a cascade of stress hormones.
Addisonians are advised to double or triple oral glucocorticoid doses if vomiting or diarrhea persists beyond 24 hours. IV fluids and medication may be necessary if the situation can’t be managed at home. Anti-nausea and anti-diarrheal medications can help control symptoms. Dietary adjustments to avoid trigger foods may also reduce incidence of GI issues.
Decreased Oral Intake
Taking daily corticosteroid doses is imperative for adrenal health in Addison’s patients. Vomiting, illnesses impacting appetite, and some medications that suppress hunger signals can all interfere with adequate oral intake of glucocorticoids. Missing doses leads to lower circulating cortisol levels.
Patients who are managing decreased oral intake due to any medical issue should speak to their provider about alternate delivery methods for corticosteroid replacement, like injections or IV administration. Stress dosing will help bridge the gap until normal eating can resume.
Certain Medications
Some prescription and over-the-counter drugs are known to interact with glucocorticoids like prednisone and hydrocortisone, making them less effective. This increases the risk of adrenal insufficiency. Drugs that accelerate liver metabolism of steroids include:
– Phenytoin
– Phenobarbital
– Rifampin
– Ephedrine
– Aminoglutethimide
– Mitotane
Patients taking these medications may need higher steroid doses for full adrenal coverage. All new medications should be reviewed for potential interactions.
Abrupt Steroid Withdrawal
Suddenly stopping oral steroids can trigger adrenal crisis in Addison’s patients who are dependent on replacement dosing. Adrenal suppression combined with lack of external cortisol leads to crisis. Steroid doses should only be reduced gradually under medical supervision.
Some conditions that might prompt abrupt steroid withdrawal include surgery, infections, or fractures where injected steroids are given. As the effects of these taper off, oral dosing may need to be increased to prevent dips in cortisol.
High Intensity Exercise
Strenuous exercise is another major stressor for the adrenals. High intensity interval training, endurance sports, strength training, and other vigorous physical activity can burn through cortisol more rapidly than lower intensity workouts. Athletes with Addison’s disease need to take special precautions.
Increasing glucocorticoid dosages before and after intense training sessions helps provide coverage. Paying attention to fatigue, dizziness, nausea, and low performance helps identify when reserves are dipping too low. Avoiding overtraining and supporting recovery with diet reduces demands.
Hot Weather
Heat intolerance is very common in people with Addison’s disease. Exposure to high temperatures, whether from hot sunny days or activities like strenuous yardwork on warm days, can result in risk of dehydration, salt depletion and fatigue.
Monitoring hydration and electrolytes during heat waves or exercise in hot conditions helps manage symptoms. Staying cool indoors, avoiding overexertion, and taking extra steroid doses can improve tolerance. Wearing hats, seeking shade and planning activities during cooler parts of the day also reduces adrenal strain.
Low Sodium Intake
Consuming adequate dietary sodium is very important for regulating blood volume and blood pressure in Addison’s patients. Persistently low sodium intake can lead to hypotension, dizziness, weakness and fatigue. Losses through sweating may also require increased salt intake.
Checking for low sodium levels via bloodwork helps identify deficient states. Increasing salt consumption through fluids, diet, or supplements improves adrenal function. Some public health guidelines suggest limiting sodium, but Addison’s patients need at least 2,000 – 3,000 mg per day for optimal health.
Alcohol
Drinking alcohol, especially in larger amounts, creates a double stress on the adrenal glands. First, alcohol is processed in the liver, which can accelerate metabolism and clearance of cortisol from the bloodstream. Secondly, alcohol impacts judgment, leading to behaviors that may increase risk of illness or injury.
Patients with Addison’s disease need to be cautious about alcohol consumption and should ideally limit intake to 1-2 drinks per day at most. During times of illness or adrenal stress, avoiding alcohol supports system recovery. Being well-hydrated can also counteract alcohol’s effects on cortisol levels.
Tobacco Use
Like alcohol, nicotine found in tobacco products can increase liver metabolism and cortisol clearance rates. Smoking or vaping delivers constant doses of nicotine, which may lead to chronically faster steroid breakdown in some patients.
Quitting smoking is advised to help stabilize cortisol levels. Patients who do smoke may need dose increases or more frequent dosing intervals if metabolism seems accelerated. Testing can determine if higher levels may be beneficial for smokers. Ongoing smoking increases other health risks as well in adrenal insufficiency.
Irregular Follow-Up
Addison’s requires vigilant self-care but also close medical follow-up care. Monitoring and optimizing steroid doses takes consistent bloodwork and feedback from endocrinologists. Infrequent follow-ups can miss declines in adrenal function, leading to increased risk of crisis episodes.
Experts recommend checking in with your adrenal care provider at least 2-4 times per year. New symptoms or issues should be addressed promptly for evaluation. At-home monitoring of blood pressure, temperature, and other vitals also helps patients self-assess disease status between appointments.
Non-Compliance with Medication
Taking oral steroid replacement consistently is the cornerstone of treatment for Addison’s disease. Forgetting doses, skipping days, or abrupt discontinuation of steroids has significant consequences. Within 1-2 days off medications, patients develop profound cortisol deficiency.
Setting phone alarms, pairing pills with routine daily tasks, using weekly pill organizers, and keeping extra supplies handy facilitates compliance. Loved ones can also help remind about dosing when needed. Working closely with your provider establishes the right individual regimen.
Pregnancy
Pregnancy places substantial strain on the adrenal glands due to the demands of the developing fetus. Cortisol and aldosterone needs increase during gestation. Labour and delivery also constitute major physiological stressors.
Expectant mothers require more intensive monitoring and medication adjustments. Adrenal crises during pregnancy pose risks to both mother and baby. Working with high-risk obstetricians and endocrinology ensures optimal adrenal function. Self-monitoring and stress-dose adjustments are also imperative.
Menstrual Periods
Some women with Addison’s disease report increased symptoms and adverse effects during their menstrual cycles. Monthly hormonal fluctuations may interfere with glucocorticoid activity in target tissues. Loss of fluids/electrolytes can also contribute to fatigue.
Boosting steroid doses may alleviate cyclical worsening of adrenal insufficiency symptoms. Tracking cyclical patterns helps determine when up-dosing could have benefits. Anti-inflammatory medications can also help offset pain and cramping that deplete cortisol reserves month to month.
High Altitude
Traveling to or exercising at high altitude locations poses a risk for acute mountain sickness (AMS) in Addison’s patients. The hypobaric, low-oxygen conditions at elevation spur an adrenal stress response. Without adequate reserves, cortisol levels may be insufficient to adapt properly.
Pre-altitude prophylactic steroid boosts can help mitigate risk and improve acclimatization. Gradual ascent, staying well-hydrated, and prompt descent with any concerning symptoms prevents progression to more dangerous conditions like cerebral or pulmonary edema. Portable emergency injectors provide added security.
Conclusion
Managing Addison’s disease day-to-day and during sick days or adrenal stress requires diligent attention and responsive self-care. Monitoring for exacerbating factors allows patients to deploy appropriate prevention and treatment strategies. Being attuned to personal warning signs and responding promptly prevents minor issues from escalating into crises. With thoughtful lifestyle adjustments and close medical follow-up, the condition can typically be well-controlled.