From the Guidelines
Low morning cortisol levels may indicate adrenal insufficiency, which requires prompt medical evaluation and treatment to prevent morbidity, mortality, and improve quality of life. If you have low morning cortisol, consult with an endocrinologist promptly for proper diagnosis through an ACTH stimulation test, as recommended by the 2020 guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1.
Diagnosis and Treatment
Treatment typically involves cortisol replacement therapy, usually with hydrocortisone (15-25 mg daily divided into 2-3 doses, with the largest dose in the morning) or prednisone (5-7.5 mg daily), as suggested by the 2014 consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1. Patients with adrenal insufficiency need to carry emergency medication (injectable hydrocortisone) and wear a medical alert bracelet. During illness or stress, cortisol doses should be doubled or tripled.
Causes and Symptoms
Low morning cortisol can result from primary adrenal gland dysfunction, pituitary problems affecting ACTH production, or sudden discontinuation of steroid medications. Symptoms may include:
- Fatigue
- Weakness
- Weight loss
- Low blood pressure
- Salt cravings
- Dizziness upon standing
Lifestyle Modifications
Lifestyle modifications like regular meals, adequate sleep, stress management, and moderate exercise can support adrenal function, but cannot replace necessary medication if true adrenal insufficiency exists. It is essential to note that the prevalence of adrenal insufficiency in adult and pediatric populations is significant, with approximately 1 in 8-10,000 children affected by primary adrenal insufficiency, as reported in a 2020 study 1.
Management
The management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency is crucial, and guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK provide recommendations for the management of these patients 1. Prompt medical evaluation and treatment are essential to prevent adrenal crisis and improve quality of life.
From the Research
Implications of Low Morning Cortisol Levels
- A low morning cortisol level can be an indication of adrenal insufficiency, a condition where the adrenal gland does not produce enough cortisol and/or aldosterone 2, 3.
- Adrenal insufficiency can be primary, caused by a problem with the adrenal gland, or secondary, caused by a problem with the pituitary gland or hypothalamus 2, 3.
- Low morning cortisol levels can also be seen in patients with primary adrenal insufficiency who have normal cortisol concentrations, making diagnosis more challenging 4.
Diagnostic Considerations
- A low baseline cortisol level, often <100 nmol/L, alongside raised adrenocorticotropic hormone (ACTH) can be enough to diagnose primary adrenal insufficiency 2.
- Confirmatory testing can be done using the cosyntropin (Synacthen®) stimulation test or the insulin tolerance test, which is the gold standard for secondary adrenal insufficiency 2.
- Elevated corticotropin concentrations (>300 pg/ml) are indicative of primary AI when cortisol levels are below 140 nmol/l (5 μg/dl) 4.
Treatment and Management
- The goal of treatment is to replace the deficient hormones and prevent adrenal crisis, a life-threatening medical emergency 5, 2, 3.
- Hydrocortisone replacement therapy is commonly used, with dosing regimens aimed at mimicking the normal circadian profile of cortisol secretion 5, 3, 6.
- Patient education and self-monitored dose adjustments are crucial for preventing adrenal crisis and managing the condition effectively 5, 2, 4.