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

From the Guidelines

Low cortisol, or adrenal insufficiency, can lead to severe health consequences, including adrenal crisis, a life-threatening condition, and therefore, prompt recognition and treatment are crucial to prevent morbidity and mortality. The consequences of low cortisol can be serious, including fatigue, weakness, weight loss, decreased appetite, abdominal pain, nausea, vomiting, diarrhea, low blood pressure, dizziness, and fainting 1. People with low cortisol may also experience salt cravings, hyperpigmentation (darkening of skin), mood changes, irritability, depression, and difficulty concentrating.

Key Consequences and Treatment

• Fatigue, weakness, and weight loss are common symptoms of low cortisol 1
• Adrenal crisis, a life-threatening condition, can occur in severe cases, characterized by severe pain, vomiting, diarrhea, dehydration, low blood pressure, and loss of consciousness 1
• Treatment typically involves cortisol replacement therapy, usually with hydrocortisone (15-25 mg daily in divided doses), prednisone (3-5 mg daily), or cortisone acetate (25-37.5 mg daily) 1
• Patients need to increase their medication during times of illness, injury, or stress, often doubling or tripling their usual dose 1
• They should also carry emergency medication (injectable hydrocortisone) and wear a medical alert bracelet 1

Management and Prevention

• Hydrocortisone 100 mg by intravenous (i.v.) injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone at 200 mg.24 h-1, until the patient can take double their usual oral glucocorticoid dose by mouth 1
• Patients with a long-standing diagnosis of adrenal insufficiency are often well informed about their disease, and anaesthetists should enquire closely about the patient’s history of glucocorticoid self-management, any previous episodes of adrenal crisis and how practised they are at medication adjustments for illness, injury or postoperative recovery 1
• Endocrine consultation should be part of planning before surgery or high-stress treatments 1

From the FDA Drug Label

wound healing Thin fragile skin Petechiae and ecchymoses Facial erythema Increased sweating Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness The consequences of low cortisol include:

• Thin fragile skin
• Petechiae and ecchymoses
• Impaired wound healing
• Secondary adrenocortical and pituitary unresponsiveness which can lead to inadequate response to stress 2

From the Research

Consequences of Low Cortisol

• Low cortisol levels can lead to adrenal insufficiency, a condition where the adrenal gland does not produce enough glucocorticoid and/or mineralocorticoid hormones 3.
• Adrenal insufficiency can cause non-specific symptoms, and if left untreated, can lead to adrenal crisis, a life-threatening medical emergency 3, 4.
• Low cortisol levels have been observed in patients with stress-related disorders such as chronic fatigue syndrome, fibromyalgia, and post-traumatic stress disorder, characterized by enhanced stress sensitivity, pain, and fatigue 5.
• Hypocortisolism, or low cortisol levels, may have both negative and positive effects on the organism, with some studies suggesting protective effects for the individual 5.
• The consequences of low cortisol can be managed with treatment, including hydrocortisone and fludrocortisone replacement therapy, which can help improve quality of life and prevent adrenal crisis 6, 4.
• However, treatment of glucocorticoid deficiency is challenging due to the difficulty in reproducing the normal physiological secretion of cortisol, and the lack of reliable biomarkers to determine the adequacy of treatment 4.
• Acute adrenal insufficiency, or adrenal crisis, requires prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities 4.
• Chronic glucocorticoid deficiency requires close collaboration with the patient, education, and empowerment to manage the condition and prevent crises, while avoiding the long-term adverse effects of over-replacement 4.