Adrenal insufficiency causes low cortisol levels, which can, in turn, cause hypoglycemia (low blood sugar). Severe hypoglycemia can be a symptom of an adrenal crisis, a potentially life threatening medical emergency.

Adrenal insufficiency (AI) is when your adrenal glands don’t make enough of certain hormones. This can affect several different processes in your body, including your ability to respond to stress.

One of several potential AI symptoms is experiencing blood sugar levels that are lower than normal, a condition doctors refer to as hypoglycemia.

Continue reading to learn more about the link between hypoglycemia and AI, what symptoms to look out for, and treatment and prevention strategies.

Your adrenal glands, located above each kidney, make several types of hormones, including cortisol and aldosterone. In AI, your body doesn’t make enough cortisol and often doesn’t produce enough aldosterone either.

Cortisol is probably best known as your “stress hormone,” as it helps your body respond to stress. However, it also has several other functions, including regulating blood sugar levels.

When blood sugar levels fall, your body can secrete various hormones to help restore levels. One of these hormones is cortisol, which can act on several tissues in the body to help boost your blood sugar levels.

When you have AI, your adrenal glands don’t make enough cortisol. This makes it more challenging for your body to raise your blood sugar levels when they’ve become too low.

AI can have several causes that affect cortisol levels in different ways:

  • Primary AI, also called Addison disease, is when problems within your adrenal glands lead to low cortisol and aldosterone levels.
  • Secondary AI is when the pituitary gland in your brain doesn’t make enough of a hormone called ACTH, which is what tells your adrenal glands to produce cortisol.
  • Tertiary AI occurs when the hypothalamus in your brain doesn’t make enough of a hormone called CRH, which is what tells your pituitary gland to make ACTH. This, in turn, leads to low cortisol production by your adrenal glands.

Hypoglycemia is more common in secondary AI and also in children with AI. A 2023 review suggests that it’s more likely to develop in children due to their higher energy needs for growth and lower stores of glucose (sugar) in their bodies.

Is hypoglycemia an early symptom of adrenal insufficiency?

Hypoglycemia can be an early symptom of AI. For example, two distinct cases from 2020 — a 19-year-old male and a 65-year-old female — both reported episodes of hypoglycemia as initial indicators of secondary AI.

The authors of a 2022 study note that secondary AI may be overlooked in some cases due to the absence of symptoms typically present in primary AI, such as dehydration and low blood pressure.

Further, the National Institute of Diabetes and Digestive and Kidney Diseases notes that an ACTH stimulation test is the most reliable test to diagnose secondary AI.

Some symptoms of hypoglycemia to look out for include:

If you feel as if you’re having symptoms of hypoglycemia, it’s important to seek medical care. Severe hypoglycemia can lead to loss of consciousness, seizures, and death if left untreated.

Hypoglycemia and adrenal crisis

In people with AI, significant drops in blood sugar can also be a sign of adrenal crisis. Moments of high stress can bring on an adrenal crisis. During these times, your body needs more cortisol than usual.

Some of the potential causes of an adrenal crisis include:

  • an infection or illness
  • surgery
  • a severe injury
  • intense emotional or mental stress

Signs of an adrenal crisis include:

An adrenal crisis is a medical emergency

An adrenal crisis can be life threatening. It’s vital to seek emergency medical care if you believe that you or someone else is experiencing an adrenal crisis.

You may be able to treat mild hypoglycemia by eating or drinking something that is high in sugar, like fruit juice or honey.

Treating more severe hypoglycemia often involves giving a sugar called dextrose intravenously. “Intravenous” means you receive the treatment directly into your bloodstream.

If you’re experiencing an adrenal crisis, a healthcare professional will also give you an emergency hydrocortisone injection. This helps to boost your cortisol levels quickly.

The outlook for people with AI who develop hypoglycemia can depend on its severity. For example, people with milder hypoglycemia can often undergo successful treatment with minimal complications.

However, severe hypoglycemia, such as during an adrenal crisis, can be life threatening. Some data estimates the mortality (death) rate for adrenal crisis is 0.5% to 2%.

It’s vital for people with AI to stick to their AI treatment plan and seek immediate care if they experience signs of an adrenal crisis.

If you have AI, you can help prevent hypoglycemia by sticking to your treatment plan. This typically involves replacing missing cortisol by taking hydrocortisone.

In some cases, your doctor may need to adjust your hydrocortisone dose to help prevent an adrenal crisis. Examples of when your doctor may do this include:

  • during an infection or illness
  • when you have a procedure or surgery
  • after an accident
  • during a period of intense emotional stress, such as grieving a loved one
  • at times of strenuous physical activity

In addition to taking all of your hormone replacement medications as directed by your doctor, you can also take other steps in your daily life to prevent hypoglycemia, such as:

What hormone deficiencies cause hypoglycemia?

Other hormones besides cortisol can help boost blood sugar levels, including epinephrine and growth hormone. Lower levels of these hormones may also contribute to hypoglycemia.

How does hypoglycemia affect cortisol?

Typically, low blood sugar levels stimulate cortisol production by your adrenal glands. This is why AI, which reduces cortisol production, can cause hypoglycemia to worsen.

What mimics hypoglycemia?

A variety of conditions can cause symptoms that are similar to or may mimic hypoglycemia. Some examples include:

People with AI can experience hypoglycemia. This is due to the effect that low cortisol can have on blood sugar levels.

Hypoglycemia can cause symptoms like fatigue, shaking, dizziness, and headache. In more severe cases, it can lead to seizures and loss of consciousness.

Blood sugar levels can drop steeply in people with AI who are experiencing an adrenal crisis. An adrenal crisis is a life threatening medical emergency that requires prompt treatment.

If you have AI, you can prevent hypoglycemia by carefully sticking to your AI treatment plan. You can also make dietary and lifestyle changes in your everyday life to maintain blood sugar levels, such as reducing stress and eating enough carbohydrates.