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The commonest cause is not the adrenal gland itself but a course of cortisone that has ended — and then two things count: raise the dose when ill, and carry a card.
Also known as: adrenal insufficiency · Addison’s disease (primary)
Open in the tool — with search and all the links →This compilation is for information and replaces neither medical diagnosis nor treatment. If you have symptoms, see a doctor.
The adrenal glands make cortisol, the hormone with which the body copes with strain. If it is missing, weakness, nausea, low blood pressure and an exhaustion that sleep does not repair follow. There are two routes there. In the primary form the adrenal gland itself is affected — that is Addison’s disease, which has a page of its own. Far commoner is the second form, and it is also the least known: in anyone who has taken cortisone for weeks, the control from above powers down and needs months after stopping before it starts up again. During that time there is too little cortisol, precisely when the body would need more. This applies not only to tablets but to a lesser degree to high-dose sprays, ointments and joint injections. The difference from the primary form is visible in everyday life: the skin does not darken, potassium and salt craving usually stay unremarkable. Two things are vital and rarely explained — the dose has to be raised temporarily in fever, vomiting and operations, and anyone affected carries a card. Properly accompanied, the matter is well manageable.
After longer use it is reduced in steps, to a plan and not by feel. This is where most of the trouble arises — and it is the easiest to avoid.
With fever, vomiting, diarrhoea or an operation the body needs more, not less. How much more, for how long, and from when an injection is needed belongs written down beforehand — not negotiated in the moment of illness.
In an emergency the information is decisive and the person often unable to speak. A card in the wallet and a note on the phone cost nothing.
Fasting between eight and nine, because the value falls steeply across the day. A measurement in the afternoon is hardly usable.
Skin that darkens, salt craving and a raised potassium speak for the adrenal gland itself. That form needs a second hormone as well and is followed differently.
Tablets, asthma spray, nasal spray, ointment and joint injection act together. At the appointment everything belongs listed, including what looks like little.
Hydrocortisone replaces what the adrenal cortex no longer makes — it is replacement, not treatment, spread over the day because the need is highest in the morning. Fludrocortisone additionally replaces the salt balance. The decisive point is not the daily dose but doubling or tripling it with fever, vomiting or surgery; without that adjustment an infection can turn into a crisis.
About four to eleven people per hundred thousand have the primary form. From the first signs to the diagnosis, years often pass, because tiredness, weight loss and low blood pressure are unspecific — the darker skin in hand creases and scars is the most usable clue. Cortisol is measured in the morning between six and eight. In a crisis, hours count: hydrocortisone into the vein and fluid, before the result is back.
Tiredness, nausea, aching limbs and circulatory weakness in the weeks after stopping cortisone. This is often ascribed to a relapse of the underlying illness — but it can be the sleeping control.
The blood pressure no longer catches the change of position. Together with nausea and loss of appetite this is the commonest combination.
Strain is exactly the situation in which cortisol is needed. Anyone who collapses unexpectedly hard with an ordinary flu is giving a hint.
This separates the secondary from the primary form. In Addison’s disease the creases of the hands, scars and gums turn brown; here the skin stays unchanged.
More than three weeks at a stretch, repeated bursts or high doses — including as spray, ointment or joint injection. This history belongs asked about in any unclear weakness.
The first value, and the timing belongs with it: fasting between eight and nine in the morning. A high morning value makes it unlikely, a low one calls for the stimulation test.
The value that separates the two forms. High speaks for the primary form, low or normal for the commoner secondary one after cortisone treatment.
A low sodium with no explaining reason is one of the commonest ways this diagnosis comes to light at all.
Raised above all in the primary form, because aldosterone is missing there as well. In the secondary form it usually stays normal — that helps in telling them apart too.
Makes sure the muscle lets go again after tensing. A lack favours cramps, twitching and inner restlessness — and the blood value reflects the store poorly.
Sets the excitability of muscle and nerve. A low value causes weakness and cramps, a high one is dangerous for the heart rhythm — here one measures rather than guesses.
Sets off the tensing in the muscle in the first place. A low value causes tingling around the mouth and in the fingers and cramping of the hands.
With heavy sweating both are lost together. Drinking only water dilutes the sodium further — with long exertion salt belongs with it.
The most important sentence there is, and it has nothing to do with supplements: with fever, vomiting, accident or an operation the cortisone dose must be raised, not held. Anyone who does not know that or carries no emergency card comes into danger in exactly the situation in which the body itself can supply nothing.
Here it is the reverse of almost everything else: in the form in which aldosterone is missing too, salt is lost through the kidney — craving for salt, low blood pressure and dizziness on standing up follow. Salt is then not a vice but part of the treatment, and in heat and sport more of it is needed.
A special case: liquorice acts at the same receptor as aldosterone and holds salt back. In this condition it was historically used for exactly that reason. This is not a recommendation — in everyone else the same effect drives blood pressure up and potassium down, described from about 100 g of liquorice a day over weeks.
Cortisone in replacement dose attacks bone far less than cortisone as a treatment — but it is lifelong. Vitamin D, calcium and loading therefore belong in the long-term accompaniment, with bone density measured at intervals.
Effective when deficient; effects on sleep and stress plausible but moderate. Too much causes loose stool.
With salt loss — medically guided.
Regular meals hold the blood sugar that nothing supports without cortisol. In heat, sport and diarrhoea extra salt is added — unlike elsewhere.
Worthwhile, but the replacement hormone dose has to match — before longer exertion it is often adjusted. This belongs settled with the treating team, not decided alone.