Graves and Adrenal Insuff?

[ar1281a]

Dr Mark, I posted some time ago about my specific situation and would like to know your opinion. If you may remember, I got an allerguc reaction (anaphylaxis due to a spider bite) and was put on prednisone (high dosis - 60 mg) for week and a half, then taken off the prednisone I think too fast which caused a relapse. I was put back on 50 mg of prednisones so in total I took it for a month. It seems like during that time I developed symptoms not consistent with what I was experiencing, extreme dizziness (even on the prednisone) hypotension and orhtostatic hypotension, increased HR. Increased frequency of urination, I was basically dehydrated as my body was not "absorving" the water. As it came in it went out. My endo decided to put me on a very low dosis of florinef to help and it has. Now I'm feeling bettr although I still experience some mild dizzy episodes. The theory is that there's some HPA axis suppression due to the steroids. You asked me on my previous posting if I fell worse when off the prednisone, no I fell better when off the prednisone (maybe because it was taken off slowly the second time). I have Graves and wondering if there's any connection with this as I've read there could be with hashi. My thyroid has been tested three times now and always comes back fine. I've wen thru every single test you can imagine. The only thing they recently found was low magnesium which could've triggered palpitations. Now, my endo will take me off the florinef (slowly as it seems I'm very sensitive) and will test for ACHT. So, I'd like to know what's your opinion. Thanks

[ar1281a]

HI NURSELPN,

Thanks so much for your posting. Yes, it was checked several times and was never above 109. They also did the AC1 test which was 5.2 (normal below 6). So ti doesn't seem to be the sugar level. Also, I can get these "dizzy spells" at any time and not necessarily when standing, I can be seated, reading and all of the sudden I get dizzy and sometimes my heart rate increases a bit (so I assume is the blood pressure). These episodes have gotten better though, before I would also get tingling/numbness and now I don't, but I still experience them and it's not fun. Thanks again for your input and any other thoughts are more than welcome.

[NURSELPN]

ar1281a,
You didn't mention if they checked your blood sugar at the time you were on those large doses of Prednisone. Many times when a patient is taking steroids their blood sugar will rise, as a side effect of the medication. Causing some symptoms like  excessive thirst, excessive urination, excessive hunger, wt. loss and weakness & extreme fatigue. Perhaps that's why you felt better when you got off the prednisone. Just a thought when I read your post. Good Luck & God Bless.

[tina999]

Hey all,

The excessive urination is becoming quite a theme.  Ar, myself, junaita and bw (? posted about ER trip after one day on synthroid) all noticed excessive urination as one of the first signs that something was wrong.  I could "turn" it off and on by stopping or starting T4.

I assumed the excessive urination was caused by a drop in aldosterone which led to a drop in blood salt and loss of water as well.   I think I found this info on an Addison's site back when they thought that's what I had.

"Lack of corticosteroids can cause elevated levels of sodium and retention of potassium. This leads to the inability to produce concentrated urine by the kidneys, which in turn can lead to excessive urination. Ultimately, a patient becomes dehydrated."

In Juantita and Ar's case it seems like they have secondary AI due to exogenous steroid use.  I have never taken steroids for  anything but don't test as primary AI from an ACTH stim test.  We don't know about bw as she hasn't been back by lately.  This almost suggests that one of the symptoms of "secondary" AI is somehow related to ADH seceretion and regulation (diabetes insipidus) or a mineralcorticoid deficinecy or both.  In Juantita's case hydrocortisone worked.  In mine and Ar's case florinef worked.  

Maybe Ar is the most important here-why would florinef-which mimics aldosterone -help solve symptoms of secondary AI-which by definition doesn't involve aldosterone?

Also would diabetes insipidus respond to florinef?  As I understand it you can't urinate salt without water however you can get rid of as much water as you want without salt.  All the aldosterone in the world shouldn't keep the urine in if you don't have enough ADH.

In my case there are about five other things that strongly suggest an aldosterone shortage.

uggghhhhh....my brain hurts.

[ar1281a]

Thanks Dr Mark,

My sodium level was low....maybe that's why I responded to florinef? the diabetes insipidus has to do with the diuretic hormone I believe, right?

Tina, thanks for your comments. As I mentioned, I'll go for ACHT test in a few weeks....we'll see what happens. Thanks again! how are you doing?

[ar1281a]

Also, dizziness can occur seated...not necessarily standing.

[Mark Lupo, M.D.]

Checking urine for concentration may be interesting due to the increased urinary frequency - there is a condition called diabetes inspipidus (nothing to do with sugar) that causes increased thirst and urination (usually presents with high sodium - which you have likely been tested for).  The low magnesium can cause heart palpitations.

The HPA axis suppression usually does NOT cause salt-steroid deficiency (ie, need for florinef) - there may be another cause such as neuro-depressor syncope (tested with a TILT TABLE test)that does repsond to florinef (by increasing blood volume).

Graves can be related to adrenal issues in same way hashi is (primary adrenal insufficiency in many cases due to immune system attack) - but in your case I do not think you have a primary adrenal problem - it is secondary to HPA axis suppression from prednisone and with the second course the taper sounds more reasonable.

ACTH stimulation test will confirm this - but the dizzy episodes (especially if they occur with prolonged standing) - brings up the other possiblities that may need tilt table testing.