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 or adrenal insufficiency, and how best to manage medication for exercise.

• How does exercise affect steroid levels?
• Exercise and fludrocortisone
• Personal experiences
• Are people with Addison's or adrenal insufficiency "different" when it comes to exercise?
• Example exercise programmes
• Bone health
• Key points

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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 or adrenal insufficiency, 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. 

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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 (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 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.

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Personal Experiences

Learn from others with Addison’s and adrenal insufficiency through their personal experiences. Chat with others in the Exercise and Fitness section of our online forum or head to our Blog to meet:

• Crystal a personal trainer and powerlifter
• Liv a yoga teacher
• Adam a sports coach 
• Stuart a racing driver 
• Ingrid, aged 80, who has recently taken up going to the gym, and 
• Anna a showjumper

Or over on our YouTube watch:

• Greg's straight-line mission across Wales
• Stuart - Addison's in the Alps
• Billie's 100 Flight's for Addison's

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

People with Addison’s or adrenal insufficiency 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 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. ADSHG members report that consuming a small amount of sugar/glucose (equivalent to about a Lucozade drink or a Jaffa cake) can also help!

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Be prepared for injury

When undertaking exercise there is always potential for injury, which with Addison's and adrenal insufficiency comes with added risks. But this shouldn't stop you from the benefits from exercise - simply be prepared! Make sure those you exercise with, or the staff at a gym, swimming pool etc, are aware of your medical situation and what you need, should you need their help. So make sure to carry  extra medication, your emergency hydrocortisone injection kit and a steroid card and go for it!

If exercising alone or in a remote location, such as a hike, ensure your medic alerts (steroid card, medical ID etc) are clear and easily accessible for others in case you can't tell your own story. Greg shares his experience in his straight-line mission across Wales.

Be prepared - resources to help you

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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).

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Bone Health

Key Points

Whether it's a long walk, gardening, or running a race, how much you need to 'up dose' and getting the right balance for you will inevitably involve a certain amount of trial and error. So listen to your body and do what is right for you. If you're unsure, it’s easier to take a small extra dose before exercise in anticipation of the extra strain you are putting on your body, rather than ‘powering on’ and ending up in a situation which could lead to an adrenal crisis.

Here's the ADSHG's key pieces of advice:

• Drink plenty of fluids and pay attention to salt intake (specifically, upping the amount during arduous events).
• Take a small extra dose of medication before any strenuous, prolonged or unaccustomed exercise and more if you begin to feel symptoms of low cortisol.
• Have your emergency injection kit to hand and make sure others are trained to administer it. This is particularly important if the sport is in a remote location.
• Wear medic alert jewellery or carry medical ID and a steroid card, so if you become unable to communicate, your medical needs would be clear.
• Manage your post-exercise wind-down sensibly (think sugar/glucose as well as salty snacks) and rest properly.

There are so many benefits to being physically active, so go for it and enjoy yourself! 

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

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