Recognising the lack of resources to support people with Addison's and adrenal insufficiency in managing their medication when spending time at altitude, in 2018, a team of researchers developed some guidance, which we share below
The key principles of steroid replacement at altitude
1. On the day of travel to altitude (>1500 m) switch to a double dose of hydrocortisone.
2. Remain on the higher dose for 48 hours, to acclimatize and then go back to your normal dose.
3. If, during your travels, there is a further significant (>400 m) increase in altitude, then we recommend you go back to the double dose of hydrocortisone for another 48 hours.
4. The requirements for fludrocortisone do not increase at altitude.
Following these guidelines will minimise the risk of adrenal crisis whilst at altitude however, as always, everyone is different and you need to respond to the signals your body gives you.
Shared experience: Climbing Mont Blanc!
In 2015, Stuart Jones and his friend Richard Topping climbed Mont Blanc, the highest peak in Western Europe, to raise money for the ADSHG and Great Ormond Street Hospital.
We extract, from Stuart's previous newsletter articles, the paragraphs he makes around managing Addison's or another form of adrenal insufficiency at altitude. Note, due to the extreme physical challenge of his climb, his updosing accounts for altitude and the physicality of the adventure.
Managing daily medication during the climb
I organised a face-to-face meeting with my endocrine nurse specialist
before my trip. There were two challenges that I would face; the physical effort and the altitude. We soon realised that there was very little information out there on the best medication schedule to follow in this situation.
My endocrinologist said that I shouldn’t worry about taking too much cortisol during the climb, as this wasn’t likely to have an adverse effect on me; it was not taking enough medication that I had to worry about.
Eventually, we decided that I should double my normal daily medication intake on account of the physical effort needed and double this again on account of the altitude, effectively meaning that I should take four times the amount of medication I usually take.
Did you stick to your plan for how much medication to take on each day of the climb?
I did, for the first day of the climb to base camp. As agreed, I quadrupled my daily dose of hydrocortisone – this meant taking half a tablet (5ml) every two hours. I kept the tablets in a small box in a pocket on my trouser leg. Before starting the climb, I wrote on the box how many tablets I needed to take and at what time I needed to take them. I found this extremely helpful for keeping me on track; remembering what you’ve taken when is really tough when there is so much going on.
The second day of the climb was the most challenging. From the mountain hut, you get up at 1.30am and leave the hut by 2.30am with the aim to reach the top of Mont Blanc for sunrise at about 6am. You then have a long descent, reaching civilisation again around 4pm.
This is obviously extremely physically demanding, and I found I needed to
increase my hydrocortisone dose more than expected. I took four 10mg
hydrocortisone tablets when I got up and then one whole tablet (10mg)per hour on average over the course of the climb and descent; in total I took 120mg. Under normal circumstances, I don’t usually feel the effects of being slightly under-medicated immediately, but on this day, I could feel the effects of each tablet wearing off after about 45 minutes and knew that I needed to take another one.
Did you come across any difficulties that you hadn’t foreseen?
The symptoms of altitude sickness are identical to those often experienced at the start of an adrenal crisis – extreme fatigue, fuzzy brain and nausea. After an hour or so at the hut, I started to feel awful. The guides did their best to reassure me that it was normal. It was the altitude rather than an adrenal crisis, but at the time, it was hard to know this.
I found the mental aspect of this quite distressing to deal with – I was aware that I knew more about Addison’s than anyone else there, and it was my responsibility to manage my condition. There was effectively no back-up, and I found this a lonely position to be in. The mountain environment was very alien and tiring. At some points, it was hard to know if I was feeling under-medicated or if the symptoms I was experiencing were due to the
altitude or just the overall experience.
How did you feel after the climb?
When we arrived back in Chamonix, both Dickie and I were absolutely knackered but fine. I immediately went back to my normal medication schedule. I had wondered if I would need to taper it slightly from the increased levels I had taken on the mountain, but my body felt
fine with going back to my normal dose immediately.
Addison's in the Alps
Watch to follow Stuart's adventure and how he managed his Addison's disease along the way
ADSHG Summary
Key considerations if spending time at altitude:
- Use the Altitude Protocol above.
- Discuss this with your endocrine team for specialist advice relating to your intended travel and your individual health needs.
- Don't skimp on the preparation: ensure you have sufficient daily replacement medication and emergency medication
- Don't skimp on packaging for your medication to keep it safe during exercise and travel.
- Consider the temperature range you will be experiencing and how you will store your medication
- Be aware that symptoms of altitude sickness may be very similar to those of adrenal crisis.
- Ensure those you are with are fully aware of your condition and adrenal crisis management