Tuesday, December 23, 2014

High rates of adrenal crisis seen in patients with chronic insufficiency

Who ends up going through adrenal crises? Can emotional stress trigger a crisis? Doctors insist it is not possible and advise us to rarely adjust our steroid replacement upwards in times of stress, especially emotional.

I'm please to see this recent article from December 2014 that addresses both questions. And yes, emotional stress can lead to adrenal crisis!!  Just like we Cushies, who adjust our medication daily to keep up with our lives, said. 

High rates of adrenal crisis seen in patients with chronic insufficiency

  • December 8, 2014
Adrenal crisis occurs in a large proportion of patients with chronic adrenal insufficiency, even if they are educated about managing the disease, according to research published in TheJournal of Clinical Endocrinology & Metabolism.
Deaths associated with adrenal crisis occurred in approximately 6% of cases, emphasizing the need for improved management of the life-threatening complication in patients with chronic adrenal insufficiency, German researchers wrote.
"Using for the first time a prospective approach, our study provides unequivocal evidence of a high incidence of [adrenal crisis] in patients with chronic adrenal insufficiency receiving standard replacement therapy," the researchers wrote.
Stefanie Hahner, MD, of the University of Wuerzburg, and colleagues recruited 423 patients with adrenal insufficiency (primary adrenal insufficiency, n=221; secondary adrenal insufficiency, n=202) and followed them for 2 years.
At baseline and every 6 months thereafter, patients were assessed through general questionnaire. Patients received detailed written instructions on glucocorticoid dose adaptation during stress at the outset of the study; those reporting adrenal crisis were contacted by phone.
Entire data sets were available for 364 patients (86%); 64 cases of adrenal crisis during 767.5 patient-years were documented (8.3 crises/100 patient-years).
Gastrointestinal infection, fever and emotional stress accounted for most precipitating causes (20%, respectively); other stressful events — major pain, surgery, strenuous physical activity, heat and pregnancy — or unexplained sudden onset of adrenal crisis also were documented (7%).
Patients with previous adrenal crisis were at higher risk (OR=2.85; 95% CI, 1.5-5.5); no further risk factors were identified.
During follow-up, 10 patients died, and four of these deaths were associated with adrenal crisis (0.5 adrenal crisis-related deaths/100 patient-years).
"Risk factor analysis has limited potential to identify patients at risk for [adrenal crisis], and education in glucocorticoid adjustments for stressful events will not obviate the occasional need for parenteral hydrocortisone to treat impending [adrenal crisis]," the researchers summarized. "Advances in comprehensive patient education including self-administration of parenteral hydrocortisone will be crucial to eliminate death from [adrenal crisis]."
Disclosure: This work was supported by the Else Kröner Fresenius Foundation project grant and the Federal Ministry of Education and Research.

NJ Gets Solu-Cortef on Ambulances

From the News Items and Research section of MaryO's Cushing's Help site:

The New Jersey Department of Health passed a waiver in October of last year that allows ambulances to carry Solu-Cortef, for the purposes of treating an adrenal crisis. As a result, New Jersey ambulances can be better prepared to treat adrenal insufficiency.  This news was brought to NADF by Karen Fountain of the CARES Foundation, who has been helping push state health directors to accept protocols to help treat adrenal insufficient patients during an emergency.  Adrenal insufficient people in New Jersey should contact their local EMS to make them aware of the waiver, and encourage them to carry Solu-Cortef in their ambulances. The hope is that other states, and eventually the entire country and beyond, will start having their ambulances carry the needed medication to treat adrenal crisis. http://www.nadf.us

Tumors: malignant v. benign

Both types of tumors should be feared and their patients revered.

Tuesday, December 2, 2014

My Story with Truth and Honesty

I love family and I enjoy genealogy. Recently, I found a cousin Dorotea in another country on Facebook. Seeing a post, she asked, are u sick?

Well, what do I say? That is a long and complicated answer. I have been sick for decades. How do retell that long story? How much does she want to know? How much should I drop in the lap of an unsuspecting cousin?

Right that moment, I began to tap out a reply on my iPhone. I just wrote and wrote. I guess you tell your story by just spitting it all out. You just tell the whole thing -- without shame, without embarrassment. To know me is to know the story of my life. It is long and complicated but it is important. I am important. Sick or well, I am important.

I don't want sympathy. I don't need pity.

I only want compassion that is given freely to any other human. What about the ones you love as friends or family?! I only want the compassion that I give to be returned. I don't like Cushing's. I hate it, in fact. However, I know I love my life with true intentions. I give compassion more freely now that I have lived this life. I want people to not be afraid of me and to stop avoiding me because they don't understand my disease or my life now. For those reasons, I told my story with truth and honesty.


I had two tumors on a part of my brain called the pituitary. It hangs below the brain and controls all hormones or chemicals in the body. It is called the master gland. Well, I was very sick for at least a decade and didn't know why. In April 2007, I found the disease Cushing's on the computer. I read and read. I cried. Instantly, I knew I had this disease. So for the next seven years, I have been testing for diagnosis and re-diagnosis to convince the doctors and surgeons I indeed had this super rare disease where the pituitary hormone ACTH works with the hormone cortisol from the adrenal gland to respond to stress in a loop. We know now that Cushing's is not as rare but rarely diagnosed. I had my first pituitary brain surgery in June 2009. The neurosurgeon went through my nose to the center of my head where the pituitary sits. The tumor was removed but I kept producing the hormone cortisol in excess, and that hurt all my organs and kept me very sick. I tested again. I sought help from a Cushing's specialist in Los Angeles, CA after many friends online finally got help from him. My second pituitary brain surgery was in April 2011. Again, tumor and extra cells under the pituitary were removed, but I still felt sick and was not cured. I tested again to confirm cortisol excess in my body. Indeed, I still had Cushing's and my results kept getting higher each time I tested. In August 2012, I tried a medication ketoconazole to lower my cortisol. That did the job but it pushed the cortisol I needed to live every day too low, and I was bedridden and could not wake up during the day. I had to take Ritalin or a stimulant in the am in order to counter the effects of lowering my cortisol at night which left me little cortisol to get through the day. It was a daily struggle to take care of myself and my small child at home. Cooking, cleaning, and self care were impossible. I used every bit of energy to care for my child and I had little left to do anything else. I struggled with this every day until October 2013. I had enough. The Food & Drug Administration (FDA) put limitations on long-term use of Ketoconazole due to the prevalence of liver damage. The drug had already been outlawed in the European Union. I waited as long as I could but I couldn't wait any longer. Cortisol was destroying my life and my body. I began testing for excess cortisol in early November 2013, and my cortisol levels in urine, blood and saliva were the highest I had ever had and definitely proved that my body was flooded with cortisol. It was time to end cortisol production once and for all. On New Years Eve 2013, I had a bilateral adrenalectomy or BLA, the removal of both adrenal glands that produce cortisol. While this fixed my Cushing's disease, it gave me Addison's disease. I don't produce excess cortisol. Now I produce no cortisol. The body needs cortisol! You make it and don't even know about it! I will take medication daily for the rest of my life to replace the hormones not made by my damaged pituitary gland. I take medication to replace the hormones my adrenal glands make. If I forget these adrenal medications, I could die within 24 hours. The body must have cortisol to function. I must take my meds daily and at the same times. I have struggled hourly and daily to find the right amount of medication that matches my body's needs. I get blood tests often to check my hormone levels. It has been very difficult for me, my husband, and my young daughter, and even my parents who come from out of state to help when they can by staying a few weeks to a month to help my family with the daily things I can no longer do because of the damage that Cushing's and high cortisol has done. Then and now, I suffer from muscle weakness all over my body, bone pain, back pain, extreme fatigue, osteopenia, anxiety, depression and other mental disturbances, insomnia, and other things I can't even remember I suffer from because my brain is always foggy.

What I know for sure is that I am a fighter. I will continue to fight for myself and my family who supports me daily with hugs, love, and laughs. I am an advocate to help people get diagnosis and treatment sooner. I have maintained a blog since 2008 at http://cushingsmoxie.blogspot.com because back in those days, an internet search for Cushing's produced more results for dogs and horses than humans. Well, the blog is a success with over 600,000 hits total. Many patients have contacted me through the years, and we have gotten them to diagnosis and surgical treatment. I speak to hundreds of patients a week to answer questions about testing, surgery, and surviving a life and body flooded with cortisol. They learn from me and I learn from them. This disease is very complex, very nuanced. The story is different but the damage is the same. As patients, we take care of one another. We provide a safety net where none existed before. We are ill but united. As I move forward every day, I know I am doing my best. I take a set amount of cortisol and aldosterone replacement daily. If I get stressed, my body uses up that set amount and my body has no cortisol to run basic body functions. Therefore, I avoid stress at every turn. I don't watch the news. I stay away from people who bring me down. I am fighting to fill my life with more joy and less junk. I'm looking for a sort of bliss that comes after years of being in bed, not being myself, not doing what I wanted to do. My thoughts and actions focus only on that: BLISS.

Monday, October 27, 2014

Advice for Cort-Reduction Surgery

I just made up that name. Cort reduction surgery sounds like the new wave of self help surgeries, doesn't it?

Well, as each day goes by, a new Cushie gets diagnosed and heads to surgery. One friend, Heather, has been worried about decision to undergo pituitary surgery. She mention more anxiety and growing concerns as the surgery day approaches.

I have personally been at the "Well, what's gonna happen to me now?" stage more than once.

I have been diagnosed with Cushing's FOUR times in six years. I endured the insanity of consecutive daily midnight blood draws, midnight saliva tests, and urine collections FOUR time periods in my life. I had to determine the best option to get rid of this tenacious cortisol beast that is Cushing's FOUR times. *It ain't no picnic.*

12/2007. First diagnosis -- pituitary surgery; delayed while I tried to become pregnant.
09/2008. Darling baby arrives.
06/2009. Pituitary surgery #1.

04/2009. Pituitary surgery #2.

07/2012. Started ketoconazole.

12/2013. Bilateral adrenalectomy.

Each time I tested, I faced questions I already knew would hang over me: What treatment would I face next? Will this finally work? Only each time, a decision had to be made, and I had to follow through with that decision all the way to surgery day.

As the years go on, uncertainty gets worse. Desperation sends your mind racing, while bleakness takes residence in your heart. You know the choices. You know which of your friends it worked for. As you realize you have already tried nearly everything, you also realize there are just not enough appealing choices left.

So I tell my friend to do what she can, but take a break from the worry.

"Your body is trying to trick you. Cortisol ramps up towards a stressful event like surgery, and doubt and anxiety build. Don't let it fool you. The month before surgery is always the worst. Cushing's grabs a hold of us and swings us around like a dog does his chew toy. After surgery, you will realize how clear your mind can be again once the cortisol faucet is shut off and the overflowing tub is drained of unneeded cortisol.

May I suggest doing something for yourself once a week until surgery?
Pick a day and do it.
Movies. Favorite dessert place. Buy a new purse. Go buy a good book for the hospital... Fiction ... No self help books! The days will fly by. You will be better before you know it."

With every Cushie we send to surgery, the community collectively holds its breath until the Cushie is safely through surgery and out of the hospital. We take a deep but quick breath, and we hold it again until we see the signs of excess cortisol reverse in their body over the coming months and years. Will that surgery cure them? We just never know who will make it out of the disease race track on lap 1, 2, 3, 4, or more after these surgery pit stops. "We elders just can't bring ourselves to say, Kid this may be it, or you may be back at the plate for another turn."

Only time will tell.

Saturday, October 18, 2014

Straight Talk Cushing's

It's good to have choices.

Now there are two FDA-approved drugs available for those Cushies who are not a candidate for a/another surgery but still remain uncured -- Corcept's Korlym and Novartis' Signifor. Two years ago, there were none.

The long-term benefits are clear.

The entire Cushing's community benefits from Big Pharma dollars spent to create what we all want -- disease awareness, earlier diagnosis for all patients, and better treatment options.

To this end, I want to share the fist video that I have seen from Novartis to further this shared mission. It is well done and quite informative.

Share the link and save a life.


(I tried to embed this video but this action is forbidden by the Novartis youtube channel. Click through. It is an informative video.)

Sunday, October 12, 2014

Quick, Easy, Inexpensive Cortisol Testing Should Soon Be Available on All Smartphones

June 2014

Quick, Easy, Inexpensive Cortisol Testing Should Soon Be Available on All Smartphones

Contact: Aaron Lohr
Director, Media Relations
Phone: 202.971.3654
Contact: Jenni Glenn Gingery
Manager, Media Relations
Phone: 202.971.3655

CHICAGO, IL—Researchers have developed a device that uses any smartphone to measure the cortisol concentration in saliva. The device was presented Tuesday, June 24, at ICE/ENDO 2014, the joint meeting of the International Society of Endocrinology and the Endocrine Society in Chicago.

"We have developed a method for measuring cortisol in saliva using a smartphone and a disposable test strip. This innovation enables anyone with a smartphone to measure their salivary cortisol level quickly, accurately, and affordably," said lead study author Joel R. L. Ehrenkranz, MD, director of diabetes and endocrinology of the Department of Medicine at Intermountain Healthcare in Murray, Utah.

Cortisol is a hormone made by the adrenal glands that's essential for the body's response to stress, and measuring cortisol can help diagnose adrenal diseases and monitor stress levels. Current testing for salivary cortisol levels involves collecting a saliva sample and sending it to a clinical lab for analysis.

"A lab charges about $25 to $50 for a quantitative salivary cortisol test and has a turnaround time of days to a week. This test, taken in a medical office or at home, will cost less than $5 and take less than 10 minutes," Dr. Ehrenkranz said. "The device is a reader that includes a case, a light pipe, and a lens and costs about a dollar to make. There is no battery power and it's unbreakable, passive and reusable."

Doctors worldwide can use the smartphone test to help them diagnose adrenal insufficiency and hypercortisolism and monitor physiologic variations in cortisol concentration; and individuals can monitor their own cortisol levels whenever they like. 

The software is "operating-system-agnostic," he explained, meaning that the device can be used on all platforms, including iOS, Android, Windows, and BlackBerry, and it has a universal form factor that works with all smartphones.

The person being tested inserts a straw-like saliva collector under the tongue. The collector wicks the saliva by capillary action to an immunoassay strip housed in a cassette and the cassette is inserted into the reader. The smartphone uses its camera and flash to take a picture of the saliva-coated strip and an algorithm converts the image's pixel density to a cortisol value.

Marketing this test as a cortisol assay would make it a class 2 medical device, Dr. Ehrenkranz explained. He and his research team are now collecting clinical data for the FDA submission, and hope to attain approval in 2015.

This study was privately funded.

# # #

Founded in 1916, the Endocrine Society is the world's oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology.  Today, the Endocrine Society's membership consists of over 17,000 scientists, physicians, educators, nurses and students in more than 100 countries. Society members represent all basic, applied and clinical interests in endocrinology. The Endocrine Society is based in Washington, DC. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at https://twitter.com/#!/EndoMedia.

Handheld Cortisol Sensor for PTSD via iStart.org

Let's reward the businesses out there working to make a cortisol meter!



Our cortisol sensing technology enables monitoring of stress levels non-invasively using a nanoengineered biochip and a handheld measurement device. The nanoengineered biochip is both low cost and disposable. We are working with Florida International University and the National Science Foundation's I-Corps program to assess both the market needs and market constraints of the technology from an economic perspective while finalizing the development of the initial market prototype.

- See more at: http://istart.org/startup-idea/consumer-goods-life-sciences/handheld-cortisol-sensor-for-ptsd/24000#sthash.tIzmUwin.dpuf

Researchers developing a test for real-time stress detection

Ask me! I'll participate. I have over 100 friends who have no adrenal glands. Let us test the device with you. 

- Signed, a Cushing's patient saved by bilateral adrenalectomy but needs a cortisol meter for better quality of life.


Researchers developing a test for real-time stress detection

Shekhar Bhansali (left) and Kelly Mesa (right) are fighting the negative health effects of cortisol.

Shekhar Bhansali (left) and Kelly Mesa (right) are fighting the negative health effects of cortisol.

FIU researchers are developing a test to detect in real-time a person's level of cortisol – widely known as the stress hormone – which could help soldiers with post-traumatic stress disorder (PTSD), and others who suffer from cortisol's effects, to manage its impact on their health.

Cortisol is released by the adrenal glands as part of the fight-or-flight mechanism. Elevated levels of cortisol can cause a long list of negative health effects, including depression, mental illness, heart disease and lower life expectancy.

Now, with a $50,000 grant from the National Science Foundation's Innovation Corps (I-Corps) program, Shekhar Bhansali, Alcatel-Lucent professor and chair of the Department of Electrical and Computer Engineering, and Kelly Mesa, a doctoral student in his department, are exploring the commercial potential of their research on cortisol detection. Other members of the team include Gabriel Saffold, a graduate student in entrepreneurship at the University of Central Florida, and Alison Tanner from the Florida Institute for the Commercialization of Public Research, who will serve as business mentors for the project.

They are one of 24 teams from universities around the country that will participate in national business development workshops and speak with potential customers and partners to evaluate the real-world potential of their technology. They also will use the Business Model Canvas, a popular entrepreneurial tool, to refine their business model.

Cortisol levels currently can only be measured on tests done in a lab. The team's goal is to see if there can be a quantitative diagnosis for PTSD through a quick test done with a sample of sweat or saliva. The proposed sensor has the potential to aid soldiers with PTSD by providing a tool that allows them to monitor their stress levels throughout the day, Mesa said.

FIU has established itself as a leader in the detection of cortisol through its nanotechnology research. One of four partner universities in the NSF's Nanosystems Engineering Research Center for Advanced Self-Powered Systems of Integrated Sensors and Technologies (ASSIST), FIU is a leader in a national nanotechnology research effort to create small, wearable, self-powered devices that will help people monitor their health.

The FIU team's research involves building a sensor on a strip and the electronics to read it. Within the six-month duration of the NSF grant, the team will determine whether their research is worthy of pursuit.

"We need to understand what our potential customers' needs are and see if our technology can be engineered to serve them," said Bhansali, the team's principal investigator.

Electrochemical sensing of cortisol

Electrochemical sensing of cortisol: a recent update.


Singh A, Kaushik A, Kumar R, Nair M, Bhansali S.


Appl Biochem Biotechnol. 2014 Oct;174(3):1115-26. doi: 10.1007/s12010-014-0894-2. Epub 2014 Apr 11.



Psychological stress caused by everyday lifestyle contributes to health disparities experienced by individuals. It affects many biomarkers, but cortisol - "a steroid hormone" - is known as a potential biomarker for psychological stress detection. Abnormal levels of cortisol are indicative of conditions such as Cushing's syndrome Addison's disease, adrenal insufficiencies and more recently post-traumatic stress disorder (PTSD). Chromatographic techniques, which are traditionally used to detect cortisol, are a complex system requiring multistep extraction/purification. This limits its application for point-of-care (POC) detection of cortisol. However, electrochemical immunosensing of cortisol is a recent advancement towards POC application. This review highlights simple, low-cost, and label-free electrochemical immunosensing platforms which have been developed recently for sensitive and selective detection of cortisol in bio-fluids. Electrochemical detection is utilized for the detection of cortisol using Anti-Cortisol antibodies (Anti-Cab) covalently immobilized on nanostructures, such as self-assembled monolayer (SAM) and polymer composite, for POC integration of sensors. The observed information can be used as a prototype to understand behavioral changes in humans such as farmers and firefighters. Keeping the future directions and challenges in mind, the focus of the BioMEMS and Microsystems Research Group at Florida International University is on development of POC devices for immunosensing, integration of these devices with microfluidics, cross validation with existing technologies, and analysis of real sample. 


 24723204 [PubMed - in process]


 PMC4179985 [Available on 2015/10/1]
Full text: Springer

Continuous subcutaneous hydrocortisone infusion viable option to normalize cortisol

"Continuous subcutaneous hydrocortisone infusion viable option to normalize cortisol

Øksnes M. J Clin Endocrinol Metab. 2014;doi:10.1210/jc.2013-4253.

  • February 24, 2014

Continuous subcutaneous hydrocortisone infusion was a safe approach for decreasing adrenocorticotropic hormone and cortisol levels to a normal circadian level with minimal adverse effects on glucocorticoid metabolism compared with conventional oral hydrocortisone replacement therapy, according to results in a prospective crossover study.

These data suggest a physiological glucocorticoid replacement therapy may be beneficial and that the infusion may become an option for patients with poorly controlled levels such as those with Addison's disease, according to Marianne Øksnes, MD,of the department of clinical science and department of medicine at the University of Bergen in Norway, and colleagues.

Patients with Addison's disease (n=33) were assessed at baseline and after 8 and 12 weeks in each treatment arm, according to data.

The infusion allowed the normalization of adrenocorticotropic hormone (ACTH) and cortisol levels, and 24-hour salivary cortisol curves appeared to reach normal circadian variation, the researchers wrote.

"This study shows that [continuous subcutaneous hydrocortisone infusion] can safely re-establish the circadian cortisol rhythm and normalize morning ACTH levels in [Addison's disease] patients, which is in sharp contrast to the typical daytime cortisol peaks and troughs and elevated morning ACTH seen with [oral hydrocortisone] treatment," researchers wrote.

The oral hydrocortisone yielded major alterations in glucocorticoid metabolites and metabolic enzyme activities, according to researchers. However, the infusion appeared to restore glucocorticoid metabolism close to normal.

No significant between-treatment differences were observed in sleep outcomes, according to data.

Additional studies are warranted to determine further ultradian rhythm improvement outcomes for patients with Addison's disease.

Disclosure: The researchers report no relevant financial disclosures."

Wednesday, October 1, 2014

Learning to Love Yourself while Cushie

A new friend who is facing a Cushing's diagnosis lamented her recent attempt to find a swimsuit for her pregnant-looking Cushie body. She knew she didn't need to let changes to her body affect her image of herself, but it did. She knew she was using society's standards as the yardstick of her personal worth. She asked us for advice.

This topic has invaded the conversations of Cushies for my whole eight years and probably even before. The damage of high cortisol is pervasive, altering the total self --mind, body, and soul. With debilitating effects from a disease no one has heard of (except the vets in your life), the Cushie feels an unfair burden to be a good patient: positive, happy, and strong, not letting the disease change who you are.

Cushing's is insidious. It breaks you down on the inside and outside, and it never lets up. The disease itself prevents you from having the strength in body and mind to fight. Others simply don't understand.

High cortisol damages your muscles including your heart, steals your physical strength, and keeps you from doing daily chores that you never use to consider real activity in your days. Forget climbing stairs, getting up easily from a chair, or standing for five minutes. Cushing's says no to that.

High cortisol also gives you additional
diseases that specialists never consider are related to each other: acid reflux, diabetes, irritable bowels, broken bones, tooth problems, headaches, and unrelenting fatigue. Others do not understand how fatigue cloaks a Cushie in a cement blanket that eliminates any fun of celebrations, family gatherings, or simple trips to the market.

High cortisol affects your brain with anxiety, depression, memory lapses, and confusion. Cushing's makes you feel dumb.

High cortisol takes your ego and replaces it with "ugly symptoms" of unstoppable weight gain, excess hair where women shouldn't have it, red or purple stretch marks, acne, hair falling out, and that buffalo hump you notice when you put your hair in a ponytail.

With all this swirling in my mind, I answered my new friend. On New Years Eve 2013, bilateral adrenalectomy began my escape from high cortisol, after seven grueling years of fighting for a cure.

"This disease is awful. No doubt. Welcome to the days when you learn to love yourself for all that you are, not what you can do or what you look like. In the end, not caring what others think is a very good lesson Cushies learn, and while difficult, it is exactly what we need to learn."

Saturday, September 20, 2014

Growth Hormone Replacement can cause Adrenal Crisis

Health Alert: Adrenal Crisis Causes Death in Some People Who Were Treated with hGH

Doctors conducting the follow-up study of individuals treated with hGH looked at causes of death among recipients and found some disturbing news. Many more people have died from a treatable condition called adrenal crisis than from CJD. This risk does not affect every recipient. It can affect those who lack other hormones in addition to growth hormone. Please read on to find out if this risk applies to you. Death from adrenal crisis can be prevented. 

Adrenal crisis is a serious condition that can cause death in people who lack the pituitary hormone ACTH. ACTH is responsible for regulating the adrenal gland. Often, people are unaware that they lack this hormone and therefore do not know about their risk of adrenal crisis. 

Most people who were treated with hGH did not make enough of their own growth hormone. Some of them lacked growth hormone because they had birth defects, tumors or other diseases that cause the pituitary gland to malfunction or shut down. People with those problems frequently lack other key hormones made by the pituitary gland, such as ACTH, which directs the adrenal gland to make cortisol, a hormone necessary for life. Having too little cortisol can be fatal if not properly treated. 

Treatment with hGH does not cause adrenal crisis, but because a number of people lacking growth hormone also lack ACTH, adrenal crisis has occurred in some people who were treated with hGH. In earlier updates we have talked about how adrenal crisis can be prevented, but people continue to die from adrenal crisis, which is brought on by lack of cortisol. These deaths can be prevented. Please talk to your doctor about whether you are at risk for adrenal crisis. 

  • Why should people treated with hGH know about adrenal crisis? Among the people who received hGH, those who had birth defects, tumors, and other diseases affecting the brain lacked hGH and often, other hormones made by the pituitary gland. A shortage of the hormones that regulate the adrenal glands can cause many health problems. It can also lead to death from adrenal crisis. This tragedy can be prevented. 
  • What are adrenal hormones? The pituitary gland makes many hormones, including growth hormone and ACTH, a hormone which signals the adrenal glands to make cortisol, a hormone needed for life. If the adrenal gland doesn't make enough cortisol, replacement medications must be taken. The most common medicines used for cortisol replacement are: 
    • Hydrocortisone 
    • Prednisone 
    • Dexamethasone 
  • What is adrenal crisis? Adrenal hormones are needed for life. The system that pumps blood through the body cannot work during times of physical stress, such as illness or injury, if there is a severe lack of cortisol (or its replacement). People who lack cortisol must take their cortisol replacement medication on a regular basis, and when they are sick or injured, they must take extra cortisol replacement to prevent adrenal crisis. When there is not enough cortisol, adrenal crisis can occur and may rapidly lead to death. 
  • What are the symptoms of lack of adrenal hormones? If you don't have enough cortisol or its replacement, you may have some of these problems: 
    • feeling weak 
    • feeling tired all the time 
    • feeling sick to your stomach 
    • vomiting 
    • no appetite 
    • weight loss 

    When someone with adrenal gland problems has weakness, nausea, or vomiting, that person needs immediate emergency treatment to prevent adrenal crisis and possible death. 

  • Why are adrenal hormones so important? Cortisol (or its replacement) helps the body respond to stress from infection, injury, or surgery. The normal adrenal gland responds to serious illness by making up to 10 times more cortisol than it usually makes. It automatically makes as much as the body needs. If you are taking a cortisol replacement drug because your body cannot make these hormones, you must increase the cortisol replacement drugs during times of illness, injury, or surgery. Some people make enough cortisol for times when they feel well, but not enough to meet greater needs when they are ill or injured. Those people might not need cortisol replacement every day but may need to take cortisol replacement medication when their body is under stress. Adrenal crisis is extremely serious and can cause death if not treated promptly. Discuss this problem with your doctor to help decide whether you need more medication or other treatment to protect your health. 
  • How is adrenal crisis treated? People with adrenal crisis need immediate treatment. Any delay can cause death. When people with adrenal crisis are vomiting or unconscious and cannot take medicine, the hormones can be given as an injection. Getting an injection of adrenal hormones can save your life if you are in adrenal crisis. If you lack the ability to make cortisol naturally, you should carry a medical ID card and wear a Medic-Alert bracelet to tell emergency workers that you lack adrenal hormones and need treatment. This precaution can save your life if you are sick or injured. 
  • How can I prevent adrenal crisis? 
    • If you are always tired, feel weak, and have lost weight, ask your doctor if you might have a shortage of adrenal hormones. 
    • If you take hydrocortisone, prednisone, or dexamethasone, learn how to increase the dose when you become ill. 
    • If you are very ill, especially if you are vomiting and cannot take pills, seek emergency medical care immediately. Make sure you have a hydrocortisone injection with you at all times, and make sure that you and those around you (in case you're not conscious) know how and when to administer the injection. 
    • Carry a medical ID card and wear a bracelet telling emergency workers that you have adrenal insufficiency and need cortisol. This way, they can treat you right away if you are injured. 

Remember: Some people who lacked growth hormone may also lack cortisol, a hormone necessary for life. Lack of cortisol can cause adrenal crisis, a preventable condition that can cause death if treated improperly . Deaths from adrenal crisis can be prevented if patients and their families recognize the condition and are careful to treat it right away. Adrenal crisis is a medical emergency. Know the symptoms and how to adjust your medication when you are ill. Taking these precautions can save your life. 


# # #

National Endocrine and Metabolic Diseases Information Service

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Internet:  www.endocrine.niddk.nih.gov

The National Endocrine and Metabolic Diseases Information Service is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health, which is part of the U.S. Department of Health and Human Services.

The NIDDK conducts and supports biomedical research. As a public service, the NIDDK has established information services to increase knowledge and understanding about health and disease among patients, health professionals and the public.

This publication is not copyrighted. The NIDDK encourages users of this publication to duplicate and distribute as many copies as desired.

September 2010


Page last updated September 24, 2012

Monday, September 15, 2014

Compassion Breeds Solidarity

My compassion for and interest in illnesses, especially the rare or mysterious, has exploded since my Cushing's diagnosis in 2007. I now can relate to the pain and suffering, the daily struggle, the dashed hopes and dreams punctured by mental and physical ailments. This is a hard life, we can all try out best, but wow, it's a lot to bare. I've also become friends with many mother-child pairs, as the parent fights for the diagnosis and treatment of the child's Cushing's. That experience in blood draws, midnight testing, brain MRIs, brain surgeries, and withdrawal symptoms is also my experience. I totally agree: this life is not glamorous at all.

Take a moment to read this story from a teenager who is chronically ill. As an aside, several Cushing's patients develop POTS after bilateral adrenalectomy, but we patients can not determine the pattern or relationship between the two illnesses. 

Sunday, September 14, 2014

Lessons of Alexis Shapiro: Texas Girl's Ordeal Spotlights Silent Crisis

Image: Alexis Shapiro 

Lessons of Alexis Shapiro: Texas Girl's Ordeal Spotlights Silent Crisis


A Texas pre-teen's medically induced obesity and subsequent slim-down has led her parents to a broader mission: Ensure that people with dangerous adrenal insufficiency get the right treatment in emergencies.

Alexis Shapiro's condition, caused by removal of a benign brain tumor three years ago, prompted nonstop hunger that pushed her weight above 200 pounds. Life-saving surgery in March has left her 50-plus pounds trimmer.

But her mother, Jenny Shapiro, said Alexis remains vulnerable to potentially lethal blackouts linked to adrenal insufficiency or AI — a little-known condition that a leading specialist says might be vastly underdiagnosed and could affect several million people in the U.S.

Alexis' condition must be painstakingly managed via oral steroids and 24/7 access to a needle and the drug Solu Cortef, which must be injected within 30 minutes after serious symptoms arise. Yet the vast majority of ambulances don't carry the drug.

Shapiro is banding with a network of"friends and family" impacted by AI to lobby for all EMS units to carry Solu Cortef — and to urge that all first responders learn more about the illness.

People with AI lack vital hormones produced by the adrenal glands. The paired organs sit atop the kidneys, flooding the body with chemicals that, among other things, maintain blood sugar, blood pressure and cardiac output during stress, said Dr. Michael Freemark, chief of pediatric endocrinology and diabetes at Duke University Medical Center.

Some people are born with AI. But far more — possibly "several million," said Freemark, who supports the push for EMS units to carry Solu Cortef — have secondary adrenal insufficiency caused by brain tumors (and their removals), strokes or long-term use of administered drugs like prednisone and hydrocortisone.

The worst symptoms of AI can include disorientation, shock, organ failure and death, unleashed by stress, sudden injury or illness.

"I told them she has adrenal insufficiency and was going to need her shot at the hospital. She was white as a sheet, shaking, going into crisis."

Two close calls with AI have stricken Alexis — the second aboard a jet as sheflew to Cincinnati last spring for the gastric-sleeve operation that curbed her ravenous appetite. (NBC News has followed Alexis' journey since December.)

But it was the first terrifying episode at her kitchen table about a year ago that launched Jenny Shapiro's latest fight for her daughter, who wears a medic-alert bracelet revealing she has AI. A chair accidentally landed on and fractured Alexis' pinky toe — and the injury triggered an adrenal crisis.

"Before the ambulance got there, she said everything was going dark," Sharpiro said.

The mother gave Alexis five steroid pills to swallow — what's known as a "stress dose." (She normally takes one pill in the morning, one at night.) She hoped her daughter would keep the meds down. Vomiting is a common symptom of adrenal crisis. Sharpiro also agonized about giving Alexis an emergency Solu Cortef shot in case her stomach heaved up the tablets. As the EMS team arrived, Shapiro urged them to rush Alexis to the hospital. They urged her to "calm down."

"A lot of paramedics don't know what it is. When they came to my house when Alexis was in crisis, they kind of blew me off when I kept asking if I should inject her. They didn't know what I was talking about," Shapiro said. "That, plus not having the medication on ambulances, creates a dangerous situation."

Image: Philip Hart, who died in 2009 at age 22 of an adrenal insufficiency crisis.

Philip Hart, who died in 2009 at age 22 of an adrenal insufficiency crisis.

Many people likely wouldn't learn they have AI until they lapse into a disorienting adrenal crisis, said Eric Hart. He lost his 22-year-old son, Philip, to an adrenal crisis caused by undiagnosed Addison's disease. Philip's adrenal crisis was triggered by a bout of flu.

His death spurred Hart to start 4Philip.org, a nonprofit in the Raleigh, North Carolina, area that has persuaded a local EMS training school to list adrenal shock as an illness paramedics must consider when assessing patients.

"Like Alexis' parents discovered, Solu Cortef is not carried on ambulances — something we seek to change," Hart said. "This needs to go nationwide."

Adrenal Insufficiency United is spearheading the drive to raise awareness among medics and, perhaps eventually, equip every ambulance with a $7 vial of Solu Cortef, a corticosteroid that restores the body's crashing hormonal chemistry and helps people in adrenal crisis to start recovering.

The nonprofit, based in Eugene, Oregon, was formed by Jenny Knapp, whose 18-year-old daughter was born with AI (Knapp's daughter, who wears a medic-alert necklace, prefers not to be named).

Knapp's daughter has a horror story similar to Shapiro's. The triggering incident was a car accident.

"I did not have the Solu Cortef injection with me because my (daughter's doctor) told me EMS squads carry it and would give it to her," Knapp recalls. "The ambulance got there. They didn't have it. I told them she has adrenal insufficiency and was going to need her shot at the hospital. She was white as a sheet, shaking, going into crisis. They barely looked at her."

On Tuesday, Knapp's group launched anonline petition to establish new emergency policies to treat adrenal crises, emphasizing "timely treatment prevents needless disability and death." By Friday, more than 3,000 people had signed the petition.

"You have a $7 injection versus someone becoming permanently disabled or dying from this," Knapp said. "Is this a third-world country where people are dying because of (the lack of) a $7 injection on ambulances?

"I don't blame EMS (emergency medical services) for this," Knapp said. "What they hear in training about adrenal insufficiency is maybe a couple sentences. They want to help. I'd love all EMS to carry Solu Cortef. However, that's not going to work for (all EMS units). Our solution is: 'Why don't you (paramedics and EMTs) just inject the patient-carried meds?'"

But that option is unsafe, contends Dr. Alfred Sacchetti, an emergency-room physician in Camden, New Jersey. He also speaks for the American College of Emergency Physicians (ACEP), an organization that includes EMS directors.

"If they want the ambulance squads to give their kids Solu Cortef that someone pulls out of the refrigerator, that's not fair to an EMS squad," Sacchetti said. "The paramedics would think: 'What's really in this vial? How much do they get?' The whole thing is very suspect."

The better choice, Sacchetti asserts, is to treat people in adrenal crisis with Solu Medrol, a glucocorticoid carried by every EMS responder. That drug will "buy you time," stabilizing the patient until they reach a hospital, he added.

"I've talked to some of these parents at length: 'I understand, you've got a child with a special problem and I sympathize.' But I can't say to every EMS squad: 'You must carry all of these very unusual drugs for the three people in the state who have this disease.' You couldn't justify the cost," Sacchetti said.

Freemark, the AI specialist from Duke University Medical Center, disagrees with that stance — and with the number of people perhaps afflicted. He believes all EMS units should carry Solu Cortef — and should include AI among the assessment protocols used to evaluate patients in distress.

"It is a potentially life-threatening condition," Freemark said.