Hypoglycemia and Adrenal Insufficiency: Symptoms, Treatment

Low blood sugar (hypoglycemia) can feel like your body’s fire alarm is going off… even when there’s no fire. Adrenal insufficiency can feel like your internal battery won’t hold a charge. When these two show up together, it’s not “random weirdness”there’s a real biology reason they can overlap.

This article explains how adrenal insufficiency can contribute to hypoglycemia, what symptoms to watch for, how doctors diagnose the problem, and what treatment usually looks like day-to-day and during emergencies. (Friendly reminder: this is educational info, not personal medical advice.)

Quick definitions (so we’re speaking the same language)

What is hypoglycemia?

Hypoglycemia means your blood glucose (blood sugar) is lower than your body needs for normal function. Many clinicians use below 70 mg/dL as the “treat it now” thresholdespecially for people using insulin or certain diabetes medications. Hypoglycemia can be mild, moderate, or severe (meaning you need help from someone else).

What is adrenal insufficiency?

Adrenal insufficiency happens when your body doesn’t make enough cortisol (and sometimes aldosterone). Cortisol helps regulate blood pressure, stress response, inflammation, andimportant for today’s topicblood sugar stability.

• Primary adrenal insufficiency (Addison’s disease): the adrenal glands themselves are damaged and can’t make enough hormones.
• Secondary adrenal insufficiency: the pituitary doesn’t make enough ACTH (the signal hormone), so the adrenals don’t produce enough cortisol.
• Tertiary adrenal insufficiency: the hypothalamus doesn’t send enough CRH (upstream signaling), often related to long-term steroid use and withdrawal.

Why adrenal insufficiency can trigger low blood sugar

Your body has a built-in “backup squad” that prevents glucose from dropping too low. When glucose falls, your liver releases stored sugar and your body releases counter-regulatory hormones to push glucose back up.

Cortisol is one of those hormones. It supports the liver’s ability to make glucose (gluconeogenesis), helps maintain energy availability during fasting, illness, and stress, and helps other hormones do their job. If cortisol is low, your body may:

• Have a harder time keeping glucose stable during fasting (overnight, missed meals, stomach bugs).
• Be more prone to “surprise lows” during illness and other stressors.
• Have weaker “bounce-back” responses after a low begins.

This is one reason adrenal insufficiency can be considered when someone has recurrent hypoglycemiaespecially when it’s happening during fasting, early mornings, or illnesses, and especially if the person is not taking glucose-lowering medications.

Symptoms: what hypoglycemia and adrenal insufficiency can look like

Common hypoglycemia symptoms

Hypoglycemia can start with classic “adrenaline” symptoms and progress to brain-related symptoms if glucose keeps dropping.

• Early signs: shakiness, sweating, hunger, fast heartbeat, anxiety/irritability, tingling.
• Neuroglycopenic signs: headache, confusion, blurry vision, clumsiness, slurred speech, behavior changes.
• Severe signs: inability to swallow safely, loss of consciousness, seizure.

Common adrenal insufficiency symptoms

Adrenal insufficiency symptoms can be frustratingly “generic,” which is why it’s sometimes missed at first. Common patterns include:

• Fatigue that doesn’t match your sleep
• Muscle weakness
• Loss of appetite, weight loss
• Nausea or abdominal pain
• Low blood pressure, dizziness when standing
• Salt cravings (more common in primary adrenal insufficiency)
• Darker skin pigmentation in some cases of primary adrenal insufficiency

Overlapping symptoms that confuse everyone

Here’s where the plot thickens: both low blood sugar and low cortisol can cause weakness, dizziness, nausea, and feeling “off.” If symptoms improve quickly after carbohydrates, hypoglycemia is more likely. If symptoms persist or keep returningespecially with weight loss, low blood pressure, or frequent illnessadrenal insufficiency may be part of the story.

Red flags: when this is an emergency

Severe hypoglycemia is an emergency

If someone is confused, can’t swallow safely, passes out, or has a seizure, treat this as an emergency. In many cases, clinicians recommend glucagon (nasal or injectable) if available and calling emergency services.

Adrenal crisis is a medical emergency

Adrenal crisis can happen when the body’s cortisol needs suddenly rise (infection, vomiting/diarrhea, surgery, major injury) and there isn’t enough cortisol available. Warning signs commonly include:

• Severe nausea/vomiting or diarrhea
• Severe abdominal pain
• Dehydration, confusion
• Very low blood pressure, fainting

Emergency care typically involves immediate hydrocortisone plus IV fluids; dextrose may be added if low blood sugar is present.

Who’s most at risk for hypoglycemia related to adrenal insufficiency?

• People with known adrenal insufficiency who have vomiting/diarrhea or can’t keep steroid medication down.
• People who recently stopped long-term steroids (prednisone, dexamethasone, etc.) or tapered too quickly.
• People with type 1 diabetes who also have autoimmune conditions (Addison’s disease can cluster with autoimmune thyroid disease and other disorders).
• Children, who have less glucose reserve and can become hypoglycemic faster.
• People with pituitary disease (secondary adrenal insufficiency) where cortisol signaling is reduced.

Diagnosis: how clinicians connect the dots

Diagnosis usually has two goals:

1. Confirm hypoglycemia as the cause of symptoms.
2. Find the underlying reason it’s happening (including whether cortisol is involved).

Confirming hypoglycemia

Clinicians often look for the classic pattern: symptoms + low measured glucose + symptom improvement after glucose rises. Home glucose meters and CGMs can be helpful, but a clinician may also want lab confirmation depending on the situation.

Testing for adrenal insufficiency

Evaluation may include morning cortisol, ACTH, electrolytes (sodium/potassium), glucose checks, and a formal test such as an ACTH (cosyntropin) stimulation test. Imaging may be used to look for pituitary or adrenal causes.

Important practical point: if someone is suspected to be in adrenal crisis, treatment should not be delayed while waiting for perfect test results. Emergency management comes first.

Treatment: what to do for hypoglycemia (right now)

Mild to moderate hypoglycemia: the “15-15” approach

If the person is awake and can swallow safely, a common approach is:

1. Take 15 grams of fast-acting carbohydrates.
2. Wait 15 minutes, then recheck glucose.
3. If still low, repeat.

Examples of ~15 grams fast-acting carbs:

• Glucose tablets or glucose gel (follow the package)
• About 4 ounces (½ cup) of regular juice or regular soda
• 1 tablespoon of sugar or corn syrup (and for children older than 1 year, honey)
• Hard candy or jellybeans (amount variescheck labels)

Once glucose is improving, a snack with carbs + protein can help prevent a rebound low if the next meal isn’t soon.

Severe hypoglycemia: glucagon and emergency help

If the person can’t swallow safely, is unconscious, or is having a seizure, emergency care is needed. Many people at risk are prescribed glucagon (nasal spray or injection) for caregivers to administer while waiting for help.

Treatment: adrenal insufficiency (the root cause piece)

Daily hormone replacement

The standard treatment for adrenal insufficiency is replacing missing hormones:

• Glucocorticoid replacement (to replace cortisol), commonly hydrocortisone taken in divided doses, or sometimes prednisone/dexamethasone depending on the person and clinician preference.
• Mineralocorticoid replacement (to replace aldosterone) with fludrocortisone in primary adrenal insufficiency; many people with secondary adrenal insufficiency don’t need this.

Stress dosing (“sick day” planning)

Because cortisol needs rise during illness and physical stress, many people with adrenal insufficiency need higher doses during times of stressfor example, fever, major dental work, surgery, or significant injury. Clinicians often provide individualized instructions, and many patients carry emergency identification and medication information.

Adrenal crisis treatment (hospital-level)

Emergency treatment typically includes immediate hydrocortisone given IV or IM plus rapid IV fluids. If hypoglycemia is present, clinicians may add dextrose to support blood sugar. This is why patients at risk are often advised to have an emergency injection plan and to seek urgent care when vomiting prevents oral medication.

When both conditions overlap: practical tips that actually help

If you have diabetes and adrenal insufficiency

This combination can be a balancing act:

• Low cortisol can increase hypoglycemia risk, especially overnight or with missed meals.
• Stress-dose steroids can raise glucose, sometimes requiring temporary insulin adjustments.
• Frequent CGM alarms or early-morning lows should prompt a discussion with an endocrinology teamthis is fixable, but rarely by guessing.

Food timing and “boring but effective” prevention

• Don’t skip mealsespecially breakfast if morning lows are common.
• Consider a balanced bedtime snack if overnight lows occur (your clinician can guide this).
• During illness, prioritize fluids and carbs you can tolerate; if vomiting prevents meds/fluids, treat it as urgent.
• Limit alcohol and never drink on an empty stomach if you’re prone to lows.

Build a two-part emergency kit

People juggling hypoglycemia risk and adrenal insufficiency often do best with a simple system:

• Fast sugar kit: glucose tabs/gel, juice box, instructions for caregivers, glucagon if prescribed.
• Adrenal kit: medical alert ID, written emergency plan, and (when prescribed) an emergency hydrocortisone injection kit.

Frequently asked questions

Can adrenal insufficiency cause hypoglycemia even without diabetes?

Yes. It’s less common than medication-related hypoglycemia, but cortisol deficiency can make fasting and illness-related lows more likelyparticularly in children and in people who can’t maintain normal intake during sickness.

Is every low blood sugar episode an adrenal crisis?

No. Hypoglycemia has many causes. But in someone with known adrenal insufficiency, a low blood sugar episode during vomiting/diarrhea, fever, confusion, or fainting is more concerning and should trigger the emergency plan.

What kind of doctor treats this?

Many cases are managed by an endocrinologist, often working with primary care and (if diabetes is involved) a diabetes care team.

Conclusion: the main takeaway

Hypoglycemia is scary because the brain needs glucose like a phone needs battery. Adrenal insufficiency makes it harder to keep that “battery level” stable, especially during fasting and illness, because cortisol supports the body’s glucose backup systems. The good news: with the right diagnosis, daily hormone replacement, smart sick-day planning, and a clear low-blood-sugar protocol, most people can reduce episodes and feel far more in control.

If symptoms are frequent, severe, or paired with low blood pressure, weight loss, repeated vomiting, confusion, or fainting, don’t tough it outget medical care promptly.

Experiences: what living with hypoglycemia + adrenal insufficiency can feel like (about )

Note: The experiences below are composites based on common clinical patterns people describe, not individual stories.

1) “Why do I feel awful every morning?”

A common early experience is waking up shaky, sweaty, and foggyespecially after a long night’s sleep or a late dinner. Some people notice they feel better within minutes after juice or glucose tablets, but then the symptoms creep back later. Over time, the pattern becomes obvious: mornings are hardest, and missed meals are a guaranteed disaster. When clinicians dig deeper, they may find clues like weight loss, low blood pressure, and persistent fatigue that point beyond “simple low blood sugar.” After evaluation, treatment with appropriate cortisol replacement (and stress-dose planning) often reduces the frequency of morning lows.

2) “A stomach bug turned into an emergency fast”

People with adrenal insufficiency often say the scariest episodes happen during vomiting or diarrhea. The problem isn’t just dehydrationif oral steroid medication can’t stay down, cortisol levels drop right when the body needs more cortisol to manage stress. Some describe an escalating spiral: nausea → can’t take meds → weakness and dizziness → confusion → fainting. Families who have an emergency plan (including when to use injectable hydrocortisone and when to go to the ER) often feel more confident and are able to act earlier, before things become dangerous.

3) “My CGM alarms all night, and I’m exhausted”

For people who also have diabetes, the experience can be extra complicated. Low cortisol can make hypoglycemia more likely, while stress-dose steroids can push glucose highersometimes in the same week. Some people describe a frustrating cycle: overnight lows lead to overcorrecting with carbs, then rebound highs, then another correction, and suddenly it’s 3 a.m. and everyone is awake. Working with a clinician to adjust insulin dosing, carbohydrate timing, and steroid schedules can smooth out the roller coaster. Many people say the biggest relief is moving from “reacting to alarms” to “predicting patterns.”

4) “I needed a plan for school/work, not just a prescription”

Another common experience is realizing that medication alone isn’t enoughlife needs a system. People often create a simple script for friends, teachers, coaches, or coworkers: what symptoms look like, where the glucose is kept, when to use glucagon, and when emergency hydrocortisone matters. This planning can feel awkward at first, but many later describe it as freeing: fewer scary surprises, less second-guessing, and more confidence traveling, exercising, and handling busy days.

5) “I stopped blaming myself”

One of the most important emotional shifts people describe is moving away from self-blame. Symptoms like fatigue, brain fog, irritability, and shakiness can be misread as laziness, anxiety, or “not managing well enough.” When the physiology is explained clearlyand when a workable action plan is in placemany people report they feel validated and more in control. The goal isn’t perfection; it’s a safer, steadier routine with fewer emergencies and faster recovery when illness hits.