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Nobody enjoys being sick. Add in the complexity of adrenal insufficiency, and illnesses become even more difficult. However, the cortisol pump does help ease some of the stress of managing adrenal insufficiency while ill or injured. Below are some scenarios a cortisol pumper might encounter with regard to illness or injury, and how to manage the pump effectively.
As with oral steroid replacement, your hydrocortisone dose will need to be increased during times of illness or other forms of stress. However, stress dosing will be managed differently with the cortisol pump.
Minor stressors can usually be handled by a bolus, and some prolonged stressors can be handled with a temporary basal increase. However, it should be noted that doubling the basal program does not translate to doubling blood cortisol levels (Hindmarsh, Geertsma 2017). Stress dosing protocol or “sick rates” may be programmed as 2.5 to 3 times the normal daily dosage of hydrocortisone (Broussard, et al 2015).
Another important factor often overlooked, is that when a non-adrenal insufficient person becomes ill or seriously injured, the production of cortisol increases and it also changes the pattern in which cortisol is produced.
“The changes in secretory patterns of cortisol seen during chronic illness are that the pulses of cortisol in the ultradian rhythm increase in amplitude and the adrenal glands continue to pulse during the night time nadir phase. This leads to the well recognized features of an over increased cortisol levels with ‘blunting’ of the diurnal rhythm.(Gibbison, et al 2013).
When ill, cortisol levels do not dip as low late at night. This means that simply increasing a typical basal program may not provide adequate night time cortisol coverage. The more stress the body is under, the more night time coverage may be necessary.
Pumpers should be set up with an alternate “sick” profile at the same time the normal basal rates are programmed. It is unwise to wait until illness strikes to program this important profile.
An example of a “sick” profile might look like:
- 12AM – 4AM: 2 mg/hr
- 4AM – 10AM: 6 mg/hr
- 10AM – 4PM: 4 mg/hr
- 4PM – 12AM: 2 mg/hr
- TOTAL: 84 mg / day
This example not only takes into account the overall increased need of cortisol, but also has a steady, elevated rate at night. Of course sick profiles need to be created for each individual, and keep in mind that a temporary basal increase or decrease can be run on a sick program as well.
Severe injuries with a long healing time may also require a sick program, or perhaps a temporary increase of the normal basal program will suffice. The type and severity of the injury must be considered on a case by case basis.
Surgeries and procedures
How you manage your steroid during and after a surgery or procedure depends on the length of the procedure, how invasive it is, and what the recovery time will be like. The Addison’s Disease Self Help Group has published a helpful handout for common medical procedures.
The pump may be worn and used during some surgeries and medical procedures at the discretion of your medical team.
It is better to have a continuous constant rate of delivery of cortisol during times of critical illness, or major surgery.
Note that it is better to have a continuous constant rate of delivery of cortisol during times of critical illness, or major surgery, etc. (Charmandari, et al 2001). This steady delivery can also be mimicked with the cortisol pump to ease the process of tapering down from post-op rates to normal basal rates once your medical has cleared you to use the pump. This would entail creating a basal profile with only one 24 hour time block (00-24), with only one delivery rate (like 8 or 10mg/hr for example). Note that this profile may not need to be run for an entire 24 hour period.
Work with your medical team to decide on a tapering plan. This plan should be flexible, and should take into account how you feel, your symptoms, and the rate at which you are recovering. Depending on the type of surgery, this might entail a few hours or days on IV hydrocortisone, a few hours or days with the pump at a continuous rate (like 8 or 10mg/hr), then switching to a “sick” profile for a few days, then using temporary basal to ease down to normal basal profile.
A tapering plan should be flexible take into account how you feel, your symptoms, and the rate at which you are recovering.
Keep in mind that when the hydrocortisone dose is very high, its generally easier to make larger decreases. As the total dose gets smaller, decreases will get tougher for the pumper, and the tapering process may be slower at that point. Not all procedures will require tapering. This should be evaluated on a case by case basis with you and your medical team.
Find out more:
Broussard, Julia R., and Naim Mitre. “Successful Use of Continuous Subcutaneous Hydrocortisone Infusion after Bilateral Adrenalectomy Secondary to Bilateral Pheochromocytoma.” Journal of Pediatric Endocrinology and Metabolism, vol. 28, no. 7-8, Jan. 2015, doi:10.1515/jpem-2014-0473.
Charmandari, E. (2001). Congenital adrenal hyperplasia: management during critical illness. Archives of Disease in Childhood, 85(1), 26–28. doi: 10.1136/adc.85.1.26
Gibbison, B., Angelini, G., & Lightman, S. (2013). Dynamic output and control of the hypothalamic-pituitary-adrenal axis in critical illness and major surgery. British Journal of Anaesthesia, 111(3), 347–360. doi: 10.1093/bja/aet077
Hindmarsh, P. C., & Geertsma, K. (2017). Congenital adrenal hyperplasia: a comprehensive guide. London: Elsevier/Academic Press.