Whether you are looking to improve your fitness or regularly engage in sports, Dr Rob Andrews offers some instructive advice on medication for exercise.

In people with healthy adrenals, exercise causes an increase in both natural hydrocortisone (cortisol) and fludrocortisone-like hormones, (mineralocorticoids). Other hormones, such as insulin, are also influenced by exercise. However, there has been little clinical research into how exercise directly affects people with Addison’s and how best to manage medication for exercise.

How does exercise affect steroid levels?

Cortisol is released from the start of exercise; how much relates to how intense the exercise is. Resistance training triggers smaller increases in cortisol than endurance, for example. Mineralocorticoids are also released during exercise, to help maintain fluid balance in the body. For people with Addison’s, the aim is to match these normal hormone-release patterns as closely as we can with extra medication.

Inevitably, a certain amount of trial and error is involved in getting the right balance for the individual. My own research has shown that managing the post-exercise wind-down sensibly also has benefits, such as consuming a small amount of sugar/glucose (equivalent to about a Lucozade drink or a Jaffa cake) within an hour of strenuous exercise. Perhaps surprisingly, this helps the body maintain its energy stores and muscle balance. 

Exercise & fludrocortisone

Those who exercise vigorously or are physically active often will lose more salt from their body through sweating. This leads to the advice that they should increase their salt intake and may also need to increase their fludrocortisone doses. Whenever you have a blood test, your doctor will measure your electrolytes (aka ‘U&E’) which includes the sodium level. The normal range for blood sodium in healthy people is 135–145 and even a slight decrease (eg. 133 or less) is significant for someone with Addison’s disease, and suggests that more fludrocortisone would be beneficial. Before making any changes to your fludrocortisone dose, always speak with your Endocrinologist and have the appropriate tests.

Therefore it is extra important for those with Addison’s to enjoy salty snacks, stay well hydrated and to make sure their fludrocortisone dose is adequate. As we also say “listen to your body”, beware of lightheadedness and obey your body if you get a salt craving! Read more in our ‘Why Salt’ article and learn more about the role of fludrocortisone on our blog. You can also learn from others with Addison’s through their personal experiences on our blog. Meet Adam a sports coach, Stuart a racing driver and Anna a showjumper.

Are people with Addison's "different" when it comes to exercise?

People with Addison’s generally need to follow the same basic principles of sensible exercise as those with healthy adrenals. You should stretch thoroughly before you commence exercise. You need to do a warm-up before and a warm-down after exercise. Take plenty of fluids during exercise and gradually increase the intensity of your exercise over time. 

Extra hydrocortisone or fludrocortisone is not usually needed for most exercise or fitness programmes, provided that you keep well hydrated and exercise within your own limits. On occasions when the exercise intensity is very high, the conditions particularly harsh (hot weather), or the exercise is prolonged (such as in competitive events like a marathon) then increases in medication may be required. 

Those who find themselves getting tense or overstrained during a competition or a training challenge, may find they need a little more medication to compensate, than would someone who is performing within their physical and emotional comfort zone. 

How much extra depends on the intensity and length of the exercise and whether it is a training day or competition day. The table below shows the guidelines I give to my patients. Individuals may find they need to adapt these slightly for their own exercise regime. 

Some example exercise programmes...

Below are three timed examples, for medium and high intensity exercise on a typical medication regime. These are for an athlete, Jo, taking a standard adrenal replacement regime.

Jo’s usual medication is 20mg hydrocortisone and 100mcg fludrocortisone per day. 

S/he splits the hydrocortisone 10/5/5 (10mg on waking, 5mg at lunchtime and 5mg at 5pm). 

Jo goes jogging for two hours, setting off at 10am. 

• At 9.30am, half an hour before s/ he sets off, s/he takes an extra 5mg hydrocortisone, equivalent to a half dose extra. 
• S/he takes the lunchtime and 5pm hydrocortisone doses as usual. 

Jo competes in a triathlon, starting at 10am, with an anticipated duration of 8 hours. 

• S/he takes the usual 10mg hydrocortisone, 100mcg fludrocortisone on waking. 
• At 9.30am s/he takes an extra 10mg hydrocortisone (1 dose extra). 
• S/he takes 10mg hydrocortisone at lunchtime and 5pm (double dose). 
• Six hours into the competition s/ he takes an extra 100mcg fludrocortisone (1 dose extra).

Jo competes in a later triathlon, this time starting at 4pm.

• S/he takes the usual medication on waking and at lunchtime. 
• At 3.30pm s/ he takes an extra 5mg hydrocortisone, followed by 10mg hydrocortisone (double dose) at 5pm. 
• Six hours into the race s/he takes 100mcg fludrocortisone (1 dose extra). 
• S/he finishes at midnight and – perhaps not surprisingly – feels unwell, so takes 5mg hydrocortisone (1 dose extra).

This article was first published in the March 2018 edition of the ADSHG magazine.

Author: Dr Rob Andrews  Consultant Senior Lecturer in Diabetes and Endocrinology at the University of Bristol and an Honorary Consultant Physician at Musgrove Park Hospital Taunton. Dr Rob Andrews undertakes specific research and work into the role that exercise and diet can play in the prevention and management of the metabolic syndrome including practical guidelines for elite athletes who have Type 1 diabetes. In Taunton he is the Clinical Lead for obesity, overseeing the development of one of the largest multidisciplinary obesity services in the country. This service was designated an International Centre of Excellence for Bariatric Surgery, one of only 2 European centres to achieve this status.

Read our blog post: "What About Sport and Exercise?" for more tips from people with Addison's and adrenal insufficiency as well as our expert panel

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