How does exercise affect steroid levels?
In people with healthy adrenals, 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 (a type of steroid hormone) are also released during exercise to help maintain fluid balance in the body.
For people with Addison’s or adrenal insufficiency, the aim is to match these normal hormone-release patterns as closely as we can with extra medication as required.
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. This helps the body maintain its energy stores and muscle balance.
Exercise & fludrocortisone
(Addison's disease/Primary adrenal insufficiency only)
Those who exercise vigorously or are physically active often lose more salt from their body through sweating. This leads to the advice that they should increase their salt intake.
People with Addison's disease (primary adrenal insufficiency) 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 (e.g. 133 or less) is significant for someone with Addison’s (primary adrenal insufficiency), 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 make sure their fludrocortisone dose is adequate. Listen to your body, beware of lightheadedness and eat salty snacks if you are craving them.
What considerations are there when exercising?
People with Addison’s or another type of adrenal insufficiency generally need to follow the same basic principles of sensible exercise as those with healthy adrenals;
- stretch/warm-up before you start to exercise (this varies from person to person)
- warm-down after exercise.
- take plenty of fluids during exercise
- gradually increase the intensity of your exercise over time.
Medication
Extra hydrocortisone (and fludrocortisone for people with Addison's disease) is not usually needed for most exercise or fitness programmes, provided that you keep well hydrated and exercise within your own limits.
However, when the exercise intensity is very high, the conditions are particularly harsh (e.g. hot weather), or the exercise is prolonged (e.g. 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 a competition day.
The table below shows the guidelines I give to my patients, but remember that everyone is different and you should always listen to your body, so you may need to adapt this for your own exercise regimen. If you feel unwell during or after exercise, you need to take an extra hydrocortisone dose immediately. Remember to also manage your post-exercise wind-down sensibly and recover properly.
Example exercise programmes
Below are three timed examples for medium and high intensity exercise on a typical medication regimen.
These are for an athlete, Jo, taking a standard adrenal replacement regimen.
Jo’s usual medication for his/her Addison's disease is 20 mg hydrocortisone and 100 mcg fludrocortisone per day. S/he splits the hydrocortisone 10-5-5 (10 mg on waking, 5 mg at lunchtime and 5 mg at 5 pm).
1. Jo goes jogging for two hours, setting off at 10 am.
- S/he takes the usual 10mg hydrocortisone, 100 mcg fludrocortisone on waking.
- At 9.30 am, 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 5 pm hydrocortisone doses as usual.
2. Jo competes in a triathlon, starting at 10 am, with an anticipated duration of 8 hours.
- S/he takes the usual 10mg hydrocortisone, 100 mcg fludrocortisone on waking.
- At 9.30 am s/he takes an extra 10mg hydrocortisone (1 dose extra).
- S/he takes 10mg hydrocortisone at lunchtime and the same at 5 pm (which is a double dose).
- Six hours into the competition s/he takes an extra 100 mcg fludrocortisone (1 dose extra).
3. Jo competes in a later triathlon, this time starting at 4 pm.
- S/he takes the usual medication on waking and at lunchtime.
- At 3.30 pm s/he takes an extra 5 mg hydrocortisone, followed by 10 mg hydrocortisone (a double dose) at 5 pm.
- Six hours into the race s/he takes 100 mcg fludrocortisone (1 dose extra).
- S/he finishes at midnight and – perhaps not surprisingly – feels unwell, so takes 5 mg hydrocortisone (1 dose extra).
