What are the implications of hypocortisolism (low cortisol levels)?

From the Guidelines

Hypocortisolism, or low cortisol levels, can have severe implications on a patient's health, including increased risk of adrenal crisis, hypotension, and electrolyte imbalances, and therefore, prompt diagnosis and treatment are crucial. The diagnosis of primary adrenal insufficiency (PAI) should be considered in all patients presenting with unexplained collapse, hypotension, vomiting, or diarrhea, as stated in the consensus statement on the diagnosis, treatment, and follow-up of patients with PAI 1.

Key Implications of Hypocortisolism

• Increased risk of adrenal crisis, which can be life-threatening if not treated promptly 1
• Hypotension, which can lead to dizziness, fainting, and decreased organ perfusion 1
• Electrolyte imbalances, including hyponatremia and hyperkalemia, which can affect cardiac and muscular function 1
• Increased risk of infections, as cortisol plays a role in immune function regulation 1

Diagnosis and Treatment

• The diagnostic test for primary PAI should be paired measurement of serum cortisol and plasma ACTH, with a synacthen-stimulated peak serum cortisol <500 nmol L-1 being diagnostic of PAI 1
• Treatment of suspected acute adrenal insufficiency should never be delayed by diagnostic procedures, and patients should receive immediate treatment with intravenous or intramuscular hydrocortisone 1
• Patients with PAI should take 15-25 mg of hydrocortisone daily in split doses, with the first dose immediately after waking and the last dose not less than 6 hours before bedtime 1

Management and Follow-up

• Patients with PAI should wear Medic Alert identification jewelry and carry a steroid/alert card, and receive sufficient education to manage daily medications and situations of minor to moderate concurrent illnesses 1
• Patients should be reviewed at least annually, with assessment of health and well-being, measurement of weight, blood pressure, and serum electrolytes, and occasional monitoring for the development of new autoimmune disorders 1

From the Research

Implications of Hypocortisolism

The implications of hypocortisolism, or low cortisol levels, can be significant and far-reaching. Some of the key implications include:

• Increased risk of adrenal crisis, a life-threatening condition that requires immediate medical attention 2
• Reduced quality of life, with patients experiencing fatigue, weakness, and other symptoms 3, 4
• Increased morbidity and mortality, with studies suggesting that patients with adrenal insufficiency have a reduced life expectancy 4
• Altered stress reactivity, with some individuals displaying attenuated cortisol responses to daily-life stressors 5
• Potential for Cushing-like symptoms or adrenal crisis due to over- or under-treatment with glucocorticoid replacement therapy 4

Clinical Presentation

The clinical presentation of hypocortisolism can vary, but may include:

• Typical symptoms such as fatigue, weakness, and weight loss
• Subclinical presentation with impaired general health status and/or hyponatremia 2
• Morning serum cortisol levels that are below normal, with a mean basal morning serum cortisol of < 110 nmol/L suggesting adrenal insufficiency 6

Diagnosis and Treatment

Diagnosis of hypocortisolism typically involves measurement of morning serum cortisol levels, as well as other tests such as the short ACTH test 6. Treatment usually involves glucocorticoid replacement therapy, with the goal of normalizing cortisol levels and improving quality of life 3, 4. However, treatment can be complex and requires careful management to avoid over- or under-treatment 4.