August 17, 2010
Hypoglycemia, Other Illnesses
Question from London, United Kingdom:
I am a 30 year old female with type 1 diabetes, autoimmune thyroid disease and primary adrenal insufficiency. I can find lots of information about each individual disease and its treatments but find it hard to find information about the interactions between the diseases. Specifically I would like to know about how adrenal insufficiency affects people with type 1 diabetes. My fasting sugars are always low (around 80 mg/dl [4.5 mmol/L]) when I wake up in the morning (I do not have nighttime hypoglycemia). Would my lack of endogenous cortisol production mean that I am less likely to suffer from the dawn phenomenon? I find hypoglycaemia stressful both physically and emotionally. Would a normal (adrenally-sufficient) diabetic produce cortisol during hypoglycaemia as part of the counterregulatory response?
I read that glucagon should not be used by people in states of adrenal insufficiency. Does this mean in a person whose adrenal insufficiency is untreated or in any person who has adrenal insufficiency regardless of treatment or not? If glucagon can’t be used, then what is the best way for an adrenally insufficient person to treat a severe hypoglycaemic reaction? Would adrenal insufficiency have any impact on hypoglycemia awareness?
Answer:
I assume you are taking replacement therapy with hydrocortisone or prednisone.
Although hypoglycemia is a side effect of hypoadrenalism, this may not be the case when you are taking replacement therapy. However, in times of stress where there is less adrenal steroid on board than is appropriate for the situation, hypoglycemia can still occur. The dawn phenomenon is associated with both elevated cortisol and growth hormone. Growth hormone would still be intact. Therefore, there still may be cause for early am insulin resistance. The issue may be one of degree.
In an adrenal sufficient person with diabetes, cortisol would be produced. However, the timing of the response is most important. Epinephrine and glucagon are necessary for an acute response to hypoglycemia. Growth hormone and cortisol are responsible for a delayed response to hypoglycemia. Therefore, the most important response is the rapid response when hypoglycemia occurs. I am not sure why a person treated with replacement glucocorticoid could not use glucagon for treatment of severe hypoglycemia.
As for your last question, no, the most important cause of hypoglycemia unawareness is loss of epinephrine response to hypoglycemia.
JTL
