Why am I still weak despite adrenal treatment?

Question

Hello doctor,

I am a 22-year-old female, 5 feet 3 inches tall, weighing 128 pounds. I have been sick for seven years. My symptoms include extreme fatigue, muscle weakness, chest tightness, nausea, brain fog, heart palpitations, dizziness, feeling lightheaded, hand tremors and spasms, facial tingling, and facial twitching.

Two years ago, I was diagnosed with adrenal insufficiency due to low cortisol levels. I was prescribed 15 mg of Hydrocortisone, which was increased to 25 mg one year later. Currently, I am taking 30 mg daily, with 15 mg in the morning and 15 mg in the evening.

I am on 14 units of Lantus insulin once daily, 1000 mg Glucophage (Metformin) twice a day, 4 mg Glimepiride once daily, 50 mg Atenolol for heart palpitations once daily, and 30 mg Hydrocortisone.

My main issue is severe fatigue and muscle weakness. I am unable to carry out daily activities, attend school, or manage household chores. I am looking for help to understand why I am still feeling this weak.

Over the past seven years, I have undergone multiple tests, including a brain MRI, chest CT, EKG, EEG, ECG, abdominal CT, and kidney and liver function tests. All results were normal except for low cortisol levels.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Your ongoing symptoms despite Hydrocortisone treatment for adrenal insufficiency need urgent medical review. Persistent severe fatigue and muscle weakness suggest possible under-replacement, electrolyte imbalance, or related complications.

Your current Hydrocortisone dose is 30 mg daily (15 mg in the morning and 15 mg in the evening), which is higher than the usual adult range of 15 to 25 mg per day. This is often given in divided doses, such as 10 mg in the morning, 5 mg at noon, and 5 mg in the evening to better mimic the natural cortisol rhythm. Despite this, symptoms like fatigue, weakness, and neurological signs such as tremors, spasms, and tingling are persisting.

This may indicate secondary adrenal insufficiency, where electrolytes are usually normal, and Fludrocortisone is not required, or primary adrenal insufficiency, where mineralocorticoid replacement such as Fludrocortisone may be needed to maintain sodium and potassium balance. Imbalance in these electrolytes can lead to palpitations and dizziness.

Facial tremors, spasms, and tingling can also be signs of electrolyte disturbances such as low calcium, magnesium, or potassium.

If you are taking medications for diabetes, such as Insulin, Metformin, or sulfonylureas like Glimepiride, along with beta blockers such as Atenolol, these may contribute to fatigue or low blood sugar episodes. Hydrocortisone can also affect blood sugar levels and may require dose adjustments in diabetes medications. Beta blockers may help control palpitations, but can sometimes cause weakness.

You should get the following tests done:

Morning cortisol and ACTH (adrenocorticotropic hormone) levels to assess adequacy of treatment.
Electrolytes include sodium, potassium, calcium, and magnesium.
Renin and aldosterone levels.
ACTH stimulation test if required.

Your doctor may consider adjusting the Hydrocortisone dose, such as dividing it into three smaller doses or using a modified-release preparation to better match the natural rhythm.

Monitor your symptoms closely and seek immediate care if there is worsening weakness, vomiting, or signs of adrenal crisis. Carrying an emergency Hydrocortisone injection is advised in such situations.

A tailored treatment plan is important to avoid both under-treatment and over-treatment.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I have gone through your query and understand your concern.

You did not mention when the cortisol levels were done. There are multiple levels of cortisol.

Were these done while you were taking Hydrocortisone?
Were they done before taking the dose?

Without knowing this, nothing can be said.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.