Pharmacy FAQ

What are the advantages and disadvantages of the different replacement hormones?

Dexamethasone is slowest to work but works the longest, often for more than 36 hours. Then follows prednisone, while cortisone acetate and especially hydrocortisone work swiftly, but their biological effectiveness is relatively short lived, (about 8-12 hours).

However, fast-acting / short-lived hydrocortisone models the physiological circadian rhythm of cortisol best.

The degree of mineralocorticoid activity of these hormones is greatest with hydrocortisone and least with dexamethasone. This means the choice of glucocorticoid will also influence Florinef dosage.

What are the advantages and disadvantages of the different replacement hormones?

Dexamethasone is a corticosteroid with a longer duration of action than prednisone. It would not interfere with the action of Florinef.

When one is using prednisone for Addison's disease does one still get the same side effects as taking it for other complaints? How long does it stay in the body? I take 5mgs in the morning end 3mgs at night time.

Prednisone is an intermediate acting glucocorticoid. Its effect lasts for 12-18 hours.

Do certain forms of contraception (e.g. the pill, implantation pellets), cause problems with hormone levels and/or medication, for women who have Primary Addison's disease?

Oral contraceptives don't pose any particular problems for Addison's patients. The oral forms are mostly oestrogen - progesterone combinations. They may cause fluid and sodium retention in some women. If so, adjustment of Florinef dosage may be required.

I have had a problem with red, dry, sore eyes and my optometrist said it could be a side effect of taking cortisone. Is this true? What do you suggest I use to help with my sore eyes?

Prolonged high doses of cortisone therapy may cause changes to the eye that lead to raised intra-ocular pressure or cataracts formation. For this reason, any symptoms that persist or are severe should be referred to a doctor. A regular eye examination would detect any of these changes.

Other causes of these symptoms could be infection, allergy or dry eyes. For dry sore eyes, where no infection is apparent, an artificial tear preparation (lubricant eye drops available without prescription) would be helpful e.g. "Poly-Tears" or "Tears Plus"

I have heard that some tablets taken for epilepsy can upset the absorption of my cortisol replacement therapy. Is this true?

Several anti-epileptic drugs commonly prescribed increase the activity of enzymes in the liver which metabolise corticosteroids. This means an increased dosage of corticosteroid (often a large increase) is needed.

Common trade names for these anti-epileptic drugs are: Tegretol, Dilantin & Prominal.

Would changing the medication help mood swings?

By medication I assume you mean cortisone or hydrocortisone. The effect corticosteroids have on mood or temperament is dose related. This may be a symptom of over-substitution and an adjustment in the dosage of cortisone may be necessary. A different cortisone could cause the same problem if the dosage is too high.

I stick to a pretty strict low-fat diet but still have high cholesterol. Can cortisone effect cholesterol?

Yes, cortisone therapy can increase cholesterol levels. Glucocorticoids increase the mobilisation of fatty acids from the fat deposits to active tissues. High dose corticoid therapy may induce marked increases in the levels of triglycerides circulating in the blood.

Is it a problem to drink alcohol, and be on steroid treatment?

There is no direct interaction between alcohol and corticosteroids. Remember that the aim is to achieve "normal" cortisol levels in an Addisonian. A moderate intake of alcohol should pose no problem.

Are there long-term side effects to be aware of when using Florinef?

In Addison's disease the combination of Florinef with a glucocorticoid, such as hydrocortisone or cortisone, provides replacement therapy, approximating normal adrenal activity with minimal risks of unwanted effects. These unwanted effects may arise from:

• Under substitution:
  • Physical Fatigue
  • Muscle Weakness
  • Nausea
  • Salt Craving
  • Low Blood Pressure

• Over substitution:
  • Unintentional Weight Gain
  • High Blood Pressure
  • Swelling of Ankles
  • Bloated Feeling

There is not increased risk of unwanted side effects with long term therapy.

I have just been to the chemist and they were out of Florinef and I have to go back tomorrow, could they have offered me any other medication in its place?

No, there is no substitute or equivalent brand of Florinef which may be used in its place. For this reason, it is important not to run right out of this or your other Addison's medications before reordering.

Is there an optimum time for taking Florinef, so that it is well - absorbed? And should Florinef always be taken with food?

There is no optimum time to take Florinef. It is usually considered best taken with/after food to minimise gastro-intestinal discomfort (this is the same for glucocorticoid replacements). Florinef can be taken at different times to your other steroid dose and/or as a split dose.

Would Dexamethasone and Florinef taken together interact in the same way as Florinef and prednisone?

No. There is no interaction between these two drugs, but they are in the same family of corticosteroids.

I have just started taking ‘The Pill’ (Triquilar ED) and have put on a lot of fluid especially in my legs, feet and stomach area. Why would this happen? Will this continue? Should I be adjusting my other tablets such as the Florinef?

Oral contraceptives may cause some degree of fluid retention as an unwanted side effect. It is possible that this may continue and, if so, may be related to the particular type of contraceptive used. Usually a tolerance to side effects develops during first 3 months of use. However, if these effects last longer or they worry you, changing to a different type of contraceptive may be of benefit so you may discuss this with your doctor.

It would not be wise, however, to alter the dosage of Florinef or other Addison’s treatment drugs unless instructed by your prescriber.

Should a patient on Florinef avoid excessive use of tea or coffee? Could this be connected to fluid retention?

Florinef is used to control the body’s water and salt metabolism. It increases the retention of salt (sodium) and water. High doses of caffeine obtained from excessive use of tea or coffee will have the opposite effect, causing increased diuresis (loss of fluid and minerals such as sodium and potassium). Moderate consumption of these beverages would be advised to avoid counteracting the effect of Florinef.

I learned the hard way that taking prednisone and Florinef together can "wash out" potassium from the body. If I take them at the same time of day, they make me feel sick. I now take the prednisone in the am, and the Florinef at lunchtime. Is there any chemical reason for feeling sick when taking the two together?

There is no chemical interaction that would prevent you from taking prednisone and Florinef at the same time. However, as they both are corticosteroids, they can affect the stomach and there could be a greater risk of ulceration.

It may be wiser to separate the doses as you suggest, particularly if only a light breakfast is taken. It is always best to take these meds with, or after, food.

Each summer I have trouble coping with the heat, and can end in crisis. Are salt tablets a good thing to take, as well as Florinef?

If you are experiencing Addisonian crises in hot weather your glucocorticoid dose may not be sufficient. This should be checked by a doctor. Salt tablets may be helpful and will not interfere with your other medications.

Can you suggest a cheaper alternative to brand name electrolyte replacement drinks, to help combat summer's heat stress?

Brands include Hydralyte, Gastrolyte and ORS. Pharmacies may also have their own brand.

Oral Rehydration solutions contain 4 main constituents:

• electrolytes, (typically sodium chloride and potassium chloride)
• a Bicarbonate source (e.g. sodium bicarbonate)
• water, to replace fluid loss
• A carbohydrate source, which maximizes absorption of fluid and electrolytes. (e.g. glucose.)

Recently I had to take a course of antibiotics and I seem to always have a severe reaction to them which involves feeling dizzy, drowsy and weak. I was told this could be caused when the liver is not functioning correctly. Would this be the reason? Note if I stop taking the antibiotics I feel fine by the end of the day.

There are very many different types and classes of antibiotics and different dosage regimes for these antibiotics. They also have different types of side-effects. As well as this you may have an individual reaction to a particular antibiotic. The symptoms you describe are most probably caused by the antibiotic, but it is unlikely that it is caused by any liver dysfunction. Dizziness is found more commonly than feeling drowsy and weak which are considered to be less common and infrequent. It could also be a combination of your infection that may be causing you to feel this way.

Usually these adverse effects are mild and transient, and it is important to complete the full course of the antibiotic. However, if any reaction concerns you, see your doctor or pharmacist for medical advice.

Is the long-term use of analgesics such as Panadeine Forte detrimental when taking steroids?

Panadeine Forte contains paracetamol and codeine phosphate, neither of which interacts or is harmful when given with steroids medication. However long-term use of codeine products is not recommended as it can cause tolerance (requiring increasing doses for efficacy) and dependence and so is best to use only when needed for short term pain relief. Side effects include constipation and drowsiness. If treatment is stopped abruptly withdrawal symptoms can occur.

NSAIDs such as Nurofen or Voltaren may be another analgesic alternative but may cause gastrointestinal ulceration or bleeding or blood pressure elevation particularly in higher doses, so caution should be exercised when using aspirin medications, particularly in long term use.

Why should an Addison’s disease patient on Rocaltrol be wary of taking Vitamin D supplements to their diet?

Rocaltrol is a potent synthetic vitamin D substance that is used to reverse the effects of osteoporosis. The difference between therapeutic and toxic concentrations is relatively small. Therefore, anyone taking Rocaltrol should avoid taking any extra vitamin D by way of supplements as this, added to vitamin D obtained from the diet and the Rocaltrol, could cause toxic effects.

Could taking Caltrate cause a burning sensation in my stomach? Can you suggest other forms in which calcium is available, which might be more suitable?

One of the main adverse side effects of taking cortisone is the loss of calcium from the bones and an increased risk of osteoporosis.

Post-menopausal women are the main victims of osteoporosis, but men can also be affected. Men usually have heavier, thicker bones than women. However, men who are taking long term corticosteroids or who are light-boned, sedentary, heavy smokers or heavy users of alcohol may be affected by osteoporosis.

Preventative calcium supplementation is very important in Addison’s patients. Calcium occurs in a wide variety of forms or "salts" in combination with other elements, e.g. calcium carbonate, calcium lactate, calcium gluconate, calcium orotate. Some calcium salts can cause gastro-intestinal irritation, flatulence and constipation.

Calcium chloride is generally considered to cause the most irritation of the commonly used calcium salts. It would be advisable to take Caltrate (calcium carbonate) with a meal to lessen irritation whereas Citracal (calcium citrate) may be absorbed well when taken with or without food.

What is in Ibuprofen, and do those with Addison’s Disease need to be wary of these products, especially in the stomach department?

Ibuprofen (-brand names such as: Nurofen ®, Advil®) is a class of pain-relieving drugs known as non-steroidal anti-inflammatory drugs or NSAIDS. These types of drugs may cause nausea, heartburn, indigestion and abdominal cramps or pain. Aspirin also belongs to this group of drugs, while paracetamol does not. There is an increased risk of gastro-intestinal bleeding or ulceration when NSAIDS and corticosteroids are given together.

I was given Gemfibrozil to help lower my cholesterol level, but this resulted in my health regressing to a state of undertreated Addison's disease. Why would this happen?

Occasionally, treatment with Gemfibrozil to lower cholesterol levels may cause myopathy, pain and weakness of the muscles. This may appear as a worsening of symptoms of Addison's disease or add to the side effects of under-substitution. Gemfibrozil may also cause more rapid breakdown of the glucocorticoid replacement therapy. Speak to your doctor and pharmacist for supplements that may help avoid this from happening.

I tried to take Celebrex for my arthritic condition, but had increased stomach discomfort. On reading the fine print, the drug company did point out that people taking steroids may suffer such side effects. Are there similar problems with other arthritis medications, especially the very new Arava (for rheumatoid arthritis)?

Drugs such as Celebrex belong to a new group of non-steroidal anti-inflammatory agents known as COX-2 Inhibitors. They have been developed specifically because they are much less likely to have effects on the stomach than older type anti-inflammatories. However, people who take steroid medication regularly (or who have a history of ulcers or gastric reflux) would need to exercise care in taking Celebrex, as effects on the stomach may still be felt.

Arava is not an anti-inflammatory but works against diseases where the body's own immune system is involved e.g. rheumatoid arthritis. It does not have the effect on the stomach that anti-inflammatories do.

What is in slow release Panadol®, and would anything in it affect those of us on steroid replacement?

Panadol Osteo® is a new and longer-acting formulation of Panadol® (paracetamol). It has a duration action of eight hours, compared to the four to six hours of normal paracetamol. As with other forms of paracetamol, it is safe to take while on steroid replacement.

Should people on steroids like cortisone acetate, prednisone, dexamethasone etc., be wary of taking ‘over-the-counter’ cold and flu medications containing pseudoephedrine?

Pseudoephedrine is found in many over-the-counter medications for colds and flu and sinus conditions. It occurs on its own, or in conjunction with pain relievers and antihistamines.

Pseudoephedrine does have effects on both the blood vessels and the heart muscle. It causes blood vessels to constrict, with a resultant increase in blood pressure. It can also cause the heart to beat faster, causing palpitations.

For these reasons people with high blood pressure, or heart conditions, should seek advice before using preparations containing pseudoephedrine. There are no problems for patients on corticosteroids and no known interactions with pseudoephedrine and steroid replacements.

What are the obvious medications (if any) that a person with Addison's should be careful of taking?

There are no drugs I know of that are contra-indicated in a person with Addison's disease.

Are there any "over the counter" medications that people on steroid replacement need to be wary of taking? (e.g. antihistamines, cough syrups, etc.)

I am not aware of any OTC medications that people on steroid replacement should avoid. However, Addison’s patients should not take mixtures containing liquorice, because of its mineralocorticoid activity.

My daughter keeps some medication in various family members cars 'just in case', will this affect the tablets in any way?

Most medications, including hydrocortisone may be adversely affected by high temperatures. Keeping your hydrocortisone in a car would not be advisable as temperatures could easily exceed 30ºC and it is recommended that storage conditions are below 25 ºC

If you wished to keep tablets in a car, it would be wise to keep them in a foam esky and not in direct sunlight. There are also special containers which may be purchased (usually to store angina tablets) that protect medications from high temperature.

Heat may also affect the injectable form of hydrocortisone.

Is there an optimum time to take a blood sugar reading, when one is on steroid replacement? (i.e. before/after steroid, and how long between the dose and the reading?)

When someone is taking steroid replacement therapy, such as in Addison’s disease, their blood levels should reach steady states approximating levels in a person who is producing their own cortisone. If the corticosteroid is taken regularly, at the same times each day, then blood sugar readings should also be taken at the same times each day, in relation to food and steroid intake.