Does hypocortisolism increase insulin levels?

From the Guidelines

Low cortisol levels can potentially decrease insulin resistance, but the direct effect of low cortisol on increasing insulin levels is not clearly established in the provided evidence. Cortisol is a stress hormone that normally raises blood glucose by promoting gluconeogenesis and reducing insulin sensitivity. When cortisol levels are low, as in conditions like adrenal insufficiency, the body may experience increased insulin sensitivity, which can lead to more efficient glucose uptake by cells, potentially reducing the need for high insulin levels 1. However, the relationship between cortisol and insulin is complex and part of the body's endocrine balance, where cortisol typically counteracts insulin's effects.

The provided evidence primarily discusses the management of hyperglycemia induced by glucocorticoid therapy rather than the effects of low cortisol levels on insulin 1, 1. In the context of glucocorticoid-induced hyperglycemia, the management involves adjusting insulin treatments based on the type and duration of action of the glucocorticoids. For instance, intermediate-acting insulin like NPH is often administered concomitantly with intermediate-acting steroids, and long-acting basal insulin may be required for long-acting glucocorticoids 1.

Given the complexity of hormonal interactions and the lack of direct evidence on low cortisol's effect on insulin levels, it is crucial to monitor blood glucose levels closely in patients with adrenal insufficiency or those on glucocorticoid therapy to adjust diabetes management as needed 1. The goal is to maintain optimal blood glucose control while minimizing the risk of hypoglycemia or hyperglycemia, which can impact morbidity, mortality, and quality of life.

Key considerations in managing patients with potential cortisol-insulin imbalances include:

• Monitoring blood glucose levels regularly
• Adjusting insulin or glucose-lowering medications based on glucocorticoid dosing and blood glucose levels
• Considering the type and duration of action of glucocorticoids when selecting insulin regimens
• Being aware of the potential for increased insulin sensitivity in patients with low cortisol levels, which may affect glucose control and insulin dosing 1.

From the Research

Cortisol and Insulin Levels

• The relationship between cortisol and insulin levels is complex, and research suggests that cortisol can affect insulin secretion and resistance.
• A study published in 2016 2 found that higher serum cortisol levels are associated with decreased insulin secretion in a Japanese population.
• Another study from 2002 3 found that patients with glucose intolerance had impaired hepatic conversion of cortisone to cortisol, which may contribute to altered cortisol action and insulin resistance.
• However, the question of whether low cortisol increases insulin levels is not directly addressed by these studies.

Effects of Cortisol on Insulin Secretion

• Research suggests that cortisol can induce insulin resistance, but its effect on insulin secretion is less clear.
• A study from 2012 4 discussed the role of glucocorticoids in type 2 diabetes, highlighting the complex interplay between cortisol, insulin resistance, and pancreatic β-cell dysfunction.
• The study from 2016 2 found a correlation between serum cortisol levels and decreased insulin secretion, but it did not investigate the effect of low cortisol on insulin levels.

Adrenal Insufficiency and Cortisol Replacement

• Studies on adrenal insufficiency and cortisol replacement therapy 5, 6 provide insight into the importance of cortisol in glucose metabolism, but they do not directly address the question of whether low cortisol increases insulin levels.
• These studies focus on the morbidity and mortality associated with adrenal insufficiency and the development of novel strategies for cortisol replacement therapy, rather than the specific relationship between cortisol and insulin levels.