Managing Addison's disease holistically

Addison’s disease is a rare condition in which the adrenal glands don’t produce enough of the hormones cortisol and aldosterone. It affects about 0.01% of people globally and can cause a range of nonspecific symptoms such as fatigue, nausea, and dizziness, which can make diagnosis tricky. Early detection helps avoid an “Addisonian crisis”, which is when adrenal hormones plummet to life-threatening levels.

Most people with Addison’s disease require lifelong hormone replacement, but nutritional strategies (including high-salt diets) can help too. Today, we’ll review the condition thoroughly — causes, symptoms, medical treatments, nutrition, and more. Let’s dive in.

What Causes Addison’s Disease?

A quick biology refresher to get us started. The adrenal glands are small organs that sit atop the kidneys. They produce several important hormones, including cortisol and aldosterone. We’ll touch on these hormones in greater depth shortly, but for now it’s sufficient to know that they come from the adrenal glands.

Another name for Addison’s disease is “adrenal insufficiency” because it’s caused by damage to the adrenal glands, preventing them from producing enough hormones. There are two types of Addison’s disease, and both can lead to Addisonian crisis.

Primary adrenal insufficiency

Primary adrenal insufficiency results from direct damage to the adrenal cortex, the specific part of the adrenal gland that makes the hormones cortisol and aldosterone.

Autoimmune conditions are the most common cause of this damage, and Addison’s disease generally. The autoimmune conditions type 1 and type 2 polyglandular syndromes in particular cause antibodies to attack healthy tissue in the adrenal glands.

Other causes of adrenal damage include infections, acute trauma (such as a car accident), cancer, genetic disorders, and certain medications.

Secondary adrenal insufficiency

Secondary adrenal insufficiency results not from damage to the adrenals, but from indirect suppression of adrenal hormones — typically via the chronic administration of steroid hormones such as cortisone, which is a manufactured steroid hormone that mimics the cortisol the adrenal glands naturally produce.

Athletes and chronic pain patients often get cortisone shots to reduce pain and inflammation, but overdoing them causes the pituitary gland in the brain to malfunction, producing less of a hormone called adrenocorticotropic hormone (ACTH). ACTH tells the adrenals to produce cortisol, so low ACTH post-chronic steroid shots lead to low cortisol levels for ~6–12 months. Folks with secondary adrenal insufficiency tend to have normal levels of aldosterone because ACTH doesn’t affect this hormone. 

Addisonian Crisis

Both primary and secondary Addison’s disease can lead to a dangerous situation called an Addisonian crisis. During an Addisonian crisis, cortisol and aldosterone levels fall to levels that are life-threatening if left untreated. Often, a “stress event” (like an infection or trauma) kicks off an Addisonian crisis in patients with Addison’s disease, quickly depleting their cortisol and landing them in the emergency room.

Why Do Low Adrenal Hormones Cause Symptoms?

It’s time for that deeper dive on the hormones cortisol and aldosterone. Adrenal insufficiency causes many symptoms because these two hormones are key players in many aspects of human health.  

Effects of low cortisol

Cortisol is a glucocorticoid hormone because it regulates blood glucose levels. During times of stress, cortisol raises blood glucose (blood sugar) to provide the body a quick energy source, while simultaneously decreasing non-essential processes like DNA repair and bone building.

While cortisol can get a bad rap as the “stress hormone,” it’s often helpful — if you’re running from an angry woodchuck or prepping for a big meeting, you want resources devoted to energy, not repair. When primary or secondary adrenal insufficiency causes cortisol to drop too low, blood sugar drops with it, leading to fatigue, hunger, weakness, and other symptoms of low blood sugar (hypoglycemia).

Cortisol also regulates blood pressure, supports our circadian rhythm, supports immunity and bone health, and more. Most cells in the human body have cortisol receptors, so it’s a significant health influencer — we need adequate amounts of this hormone to thrive.

Effects of low aldosterone

Aldosterone regulates blood pressure and your acid-base, or pH, balance, which is crucial for most physiological processes in your body. Aldosterone also works together with another hormone called renin to regulate sodium and potassium levels, which is why they’re both called mineralocorticoid hormones.

Primary adrenal insufficiency decreases aldosterone, which also has the effect of increasing renin. The net result of decreased aldosterone and increased renin is increased sodium excretion and decreased potassium excretion, causing an electrolyte imbalance.

This imbalance in sodium and potassium often leads folks with Addison’s disease to have clinically low sodium levels (called hyponatremia) and high potassium levels (called hyperkalemia). These electrolyte imbalances cause many symptoms associated with Addison’s disease.

Sex hormones

While cortisol and aldosterone are the primary hormones affected by Addison’s disease, it’s worth noting that the adrenal glands also produce small amounts of testosterone and estrogen, so these sex hormones can be somewhat depleted. One paper found that women with Addison’s disease had decreased fertility after the diagnosis was made, although the reasons for the reduced fertility were unclear. 

Let’s review the symptoms of Addison’s disease now.  

Symptoms of Addison’s Disease

Because cortisol and aldosterone play a role in so many of the body’s systems, symptoms of Addison’s disease can run the gamut. Common symptoms include fatigue, weakness, poor appetite, weight loss, nausea, vomiting, stomach pain, dizziness, tachycardia (rapid heartbeat), and hypotension (low blood pressure). These symptoms overlap with the symptoms of low sodium and high potassium, which both result from low aldosterone. 

Most patients with primary adrenal insufficiency will have skin darkening, called hyperpigmentation, especially in sun-exposed and pressure areas like the palm creases, lips, and knuckles. While secondary adrenal insufficiency lowers ACTH, primary adrenal insufficiency elevates ACTH levels, triggering melanocytes (skin cells) to produce more melanin, a chemical that darkens skin.

Severe adrenal insufficiency (Addisonian crisis) may present as confusion, severe dehydration, refractory hypertension (low blood pressure unresponsive to treatment), and shock. These symptoms are life-threatening, so prompt treatment is required. 

Diagnosing Addison’s Disease

Diagnosing Addison’s disease is tricky because the symptoms are nonspecific, meaning many other conditions can also cause them. That’s where lab work comes in. A clinician will likely measure cortisol, ideally in the early morning when cortisol peaks. A low level will prompt further testing that may include:

• Serum ACTH (elevated in primary adrenal insufficiency, suppressed in secondary)
• An ACTH stimulation test (to assess the cortisol response to ACTH)
• Serum aldosterone (low in primary adrenal insufficiency)
• Serum renin (usually high in Addison’s disease)
• Comprehensive metabolic panel (to check for hyponatremia, hyperkalemia, and hypoglycemia)
• Thyroid-stimulating hormone (may be elevated)
• Anti-adrenal antibodies (suggests autoimmune damage of the adrenal cortex)

Let’s cover medical treatments now. 

Medical Treatments for Addison’s Disease

If you think you or a loved one has Addison’s disease, consult a specialist. Most Addison’s patients will need lifelong hormone replacement to manage the condition. The treatment consists of two types of hormone replacement.

1. Glucocorticoid replacement
2. Mineralocorticoid replacement

Glucocorticoid drugs like hydrocortisone and prednisone mimic the hormone cortisol, preventing low blood sugar. Mineralocorticoid drugs like fludrocortisone mimic aldosterone while regulating renin levels, preventing electrolyte imbalances. Clinicians may administer the lowest possible doses to control symptoms since over-treatment can cause obesity, diabetes, osteoporosis, and high blood pressure. 

Addisonian crisis patients require more urgent treatment consisting of fluid and electrolyte replacement, dextrose (to restore blood sugar levels), and hormone replacement.  

Let’s talk nutrition for managing Addison’s disease now. 

Nutritional Considerations

Addison’s disease and the drugs to treat it may prompt changes to your nutritional strategy. 

Here are some areas to consider:

• Calcium and magnesium. Addison’s disease is linked to osteoporosis, so patients may benefit from a special focus on these bone-supporting minerals. Science-backed recommendations are to consume 400–600 mg of magnesium from diet and supplements, and 1 gram of calcium from diet (calcium supplements are not recommended as they can lead to arterial calcification and are linked to heart disease). 
• Vitamin D. Guidelines suggest adults consume 1500–2000 IU daily for bone health, immunity, and other functions. A small study found that high-dose vitamin D (4000 IU daily) improved autoimmune markers in 13 Addison’s patients. D3+K2 supplements specifically can help with calcium absorption.
• Antioxidants. Research indicates nutritional antioxidants like vitamin C, vitamin E, selenium, zinc, coenzyme Q10, and various polyphenols (plant-based antioxidants) may offset oxidative stress caused by adrenal hormone imbalances. Oxidative stress refers to an excess of volatile molecules (molecules that interact with oxygen in the body) that cause damage and accelerate aging. 
• Caffeine. Folks with Addison’s will want to be cautious with caffeine because it increases cortisol secretion and activates the stress response, potentially interfering with treatment and management. 
• Grapefruit and licorice. They may also want to be cautious of grapefruit and licorice, which have been shown to interact with the cortisol replacement therapy cortisone acetate. 

Some Addison’s patients also need more salt. Let’s talk more about that. 

Addison’s Disease and Sodium

Folks with primary adrenal insufficiency typically have low aldosterone levels, which causes them to excrete a boatload of sodium, increasing their risk of hyponatremia. Consequently, the NIH recommends a high-sodium diet for Addison’s patients with low aldosterone levels to keep their blood sodium in a healthy range. 

How much sodium is enough for Addison’s patients? Science hasn’t answered that question with precision yet, but we have clues.  

Dr. Simon Pearce, a Professor of Endocrinology at Newcastle University, points out that Addisonian crisis patients often consume 30–60 grams of salt (12–24 grams of sodium) via IV saline over 1–2 days to reverse hyponatremia. That’s too high for everyday maintenance, but it suggests folks with adrenal insufficiency need more salt than most. 

Consulting a trusted health practitioner can provide you a good sodium intake range to aim for. Your body can also be a guide to help dial your intake in. When you crave salt (a typical Addison’s symptom), bust out the salt shaker or a salty electrolyte drink like LMNT. The science suggests 4–6 grams of sodium is a good baseline intake for heart health, but Addison’s disease may raise these needs. Work with a trusted health practitioner and listen to your body.   

Getting enough salt has been crucial for busy mom and entrepreneur Lara Clark in managing her condition. “When I was diagnosed with Addison’s Disease, I was determined not to let it hinder me from supporting my kids,” Lara shares. “Many people with Addison’s Disease have to take a prescription to manage their body’s sodium levels, but LMNT has been huge in helping me do that on my own without taking additional meds.”⁠

Holistic Management

Addison’s disease is a thorny condition that’s easy to miss and potentially life-threatening if left untreated. Once diagnosed, it requires lifelong treatment. 

But with hormone replacement and nutritional therapies like a high-salt diet, bone health nutrients, and caution with caffeine and “energy” drinks in general, most people with Addison’s can live active, happy lives. I hope this article helps more people achieve that goal.