Can adrenal insufficiency with low cortisol levels cause nausea?

Can Low Cortisol Cause Nausea?

Yes, low cortisol from adrenal insufficiency commonly causes nausea, which is a cardinal symptom occurring in 20-62% of patients and represents a key clinical manifestation of glucocorticoid deficiency. 1, 2

Clinical Presentation of Nausea in Adrenal Insufficiency

Nausea is one of the most frequent gastrointestinal symptoms in adrenal insufficiency and often presents alongside other manifestations:

• Nausea occurs in 20-62% of patients with adrenal insufficiency, frequently accompanied by vomiting, poor appetite, and weight loss (43-73% of cases). 2
• Morning nausea and lack of appetite are particularly common symptoms in primary adrenal insufficiency (PAI) patients, often representing under-replacement of glucocorticoids. 1
• Unexplained gastrointestinal symptoms including nausea, vomiting, or diarrhea should immediately raise suspicion for adrenal insufficiency, especially when combined with hypotension or collapse. 3

Mechanism and Clinical Significance

The nausea in adrenal insufficiency reflects inadequate glucocorticoid levels:

• Under-replacement of glucocorticoids is characterized by lethargy, nausea, poor appetite, weight loss, and increased pigmentation with uneven distribution. 1
• Nausea represents a critical warning sign that can progress to adrenal crisis if not recognized and treated appropriately. 3

Practical Management Approach

When nausea is present in a patient with known or suspected adrenal insufficiency:

• Waking up earlier to take the first dose of hydrocortisone and then returning to sleep may relieve morning nausea and lack of appetite in PAI patients. 1
• Adjust the timing of glucocorticoid dosing based on when symptoms occur during the day, with detailed questioning about energy dips and symptom patterns. 1
• If nausea is severe or accompanied by vomiting, this may indicate impending adrenal crisis requiring immediate stress-dose glucocorticoids (hydrocortisone 100 mg IV) and saline infusion. 3

Critical Diagnostic Considerations

• Nausea in the context of hyponatremia (present in 90% of newly diagnosed adrenal insufficiency cases) should prompt immediate evaluation for adrenal insufficiency, as this combination can be life-threatening. 3
• Do not delay treatment of suspected adrenal crisis to perform diagnostic testing if the patient presents with nausea, vomiting, and hypotension. 3
• Morning cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH in the presence of acute illness is diagnostic of primary adrenal insufficiency and requires immediate treatment. 3

Common Pitfalls to Avoid

• Do not attribute nausea to other causes without first excluding adrenal insufficiency, particularly in patients with risk factors such as autoimmune disease, recent steroid use, or unexplained hypotension. 3
• The absence of hyperkalemia cannot rule out adrenal insufficiency, as it is present in only approximately 50% of cases, so nausea with hyponatremia alone warrants evaluation. 3
• Malabsorption of glucocorticoid replacement (e.g., from bulking agents like psyllium) can trigger nausea and adrenal crisis in patients with known adrenal insufficiency. 4