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At a most basic level, in order to use the cortisol pump, you need an infusion pump filled with Solu-Cortef. The pump should be programmable, as most insulin pumps are (VGo patch pumps are not suitable for cortisol pumping). Which type of pump you select will determine which supplies you need. Tubed pumps will require infusion sets and cartridges (also called reservoirs). An experienced endocrinologist can assist you in selecting suitable infusion sets.
The Omnipod system requires a PDM (Personal Diabetes Manager), that acts as the controller for your pods. The pods come in packs of 5 and 10. Your doctor will write a prescription for how many you need. Pods are programmed to expire after 72 hours. However, there will be times you will need to change your pod more frequently due to pod communication errors, increased dosing (pods cannot be refilled), site leaks, occlusions, or adhesive failure. It is wise to have extras.
You will need Solu-cortef (hydrocortisone). 100mg powder vials are preferred (NDC# 0009-0825-01). For more information, please see section “Should I Use Powder Vials or Act-o-vials?”. Currently there is no research or documentation of using any other type of corticosteroid in the pump.
Longer acting steroids would pose a significant challenge to replicating natural circadian rhythm of cortisol. Be advised that currently there is no generic version of injectable hydrocortisone available in the United States. Generic A-hydrocort appears in the pharmacy’s ordering system and many pharmacies will try to order the generic version. However, this medication will remain “on order” and never arrive. It is no longer in production. This will cause significant delays in setting up the pump.
To avoid this situation, pumpers always need to ensure their pharmacy orders brand Solu-Cortef. Medical providers can help by specifying “brand only” on the prescription. The quantity ordered should be enough to cover the daily dose, plus the eventuality of stress dosing and bolusing. Some extra medication can also be helpful for times when the pharmacy experiences a delay in filling the order, which is not uncommon.
Sterile Water (or something similar)
If using powder vials, you will also need something to reconstitute the medication. This can be saline (NDC# 0409-4888-02), sterile water (NDC# 0409-4887-10), or bacteriostatic water (NDC# 00409-1966-06). There should be at least 1mL for every vial of Solu-cortef. For example if a pumper has a monthly prescription for 30 vials of Solu-Cortef, they would need 3, 10mL vials of saline.
Syringes may also be needed for reconstituting the Solu-Cortef. Medtronic reservoirs do not provide a syringe. Tandem and Omnipod do provide syringes, however they are intended for loading the pump, not reconstituting medication. While they can be used for this purpose, they are less than ideal due to size or quality. BD syringes are a quality product with smooth plunger action and a variety of sizes and options. For mixing the medication large gauge needles do the job quicker and easier. Needle length needs to be fairly short for ease of retrieving the mixed Solu-Cortef from the vial, and to prevent bending the needle (BD Syringes 3mL Luer-Lok 20 Gauge 1 Inch Needle BD #309578). Large gauge needles should not be used for injection purposes.
Subcutaneous insulin syringes used with Solu-Cortef may also be needed to support pump use (BD Insulin Syringes with BD Ultra-Fine needle 1mL 31g NDC#08290-8418-01). Boluses larger than 10 units may not be absorbed well though the infusion site, and larger boluses may stress the site leading to failure, such as leaking. This is a problem.
If a pumper is in need of a large bolus, they are obviously experiencing a stressor that would only be made exponentially worse by a site failure. By that point, they may not be in a condition that they can physically change out infusion sets. Subcutaneous injections can also be used as a back up method of cortisol delivery in the event that the pump is broken or fails in some way. Manufacturers can often overnight a replacement (for a pump covered by warranty), but this would still leave the pumper in an emergency situation without a back up means of cortisol replacement.
Back-up Medication Plan
Alternatively, if the individual can tolerate oral steroids, then oral medications may be used as the back up plan. The pharmacokinetics of the oral steroids should be taken into careful consideration. The durations and peak times can be used to design a plan as close to natural circadian rhythm as possible. If the pumper’s back up plan includes oral steroids, medical providers need to ensure their patient receives a prescription for the necessary medications.
All cortisol pumpers need to be in possession of an emergency Solu-Cortef injection.
All pumpers need to be in possession of an emergency Solu-Cortef injection. The cortisol pump is never a replacement for emergency intervention. It is unlikely the pump will be able to successfully infuse such a large amount in such a small time frame. It would also be unwise to assume there is always 100+ milligrams available in the pump. An emergency situation is no time to compromise the integrity of the infusion site or empty out the pump’s cartridge. Pumpers will still need a 100mg Act-o-vial ( NDC 0009-0900-13 ) and 2 IM needles. This should be at least a 1” needle, preferably 1 1/4-1 1/2”. 25g or 27 gauge is fine for injecting.
Medical ID Bracelet
All cortisol pumpers need to wear a medical ID bracelet.
Pumpers will need to wear a medical ID bracelet indicating adrenal insufficiency and that they are wearing a cortisol pump. It’s also advisable to label the pump itself as a “cortisol pump”. Label may also include “Solu-Cortef” and the dilution ratio used, as well as “Do not disconnect”. Pumpers have many options to label the pump. Stickers can be custom ordered, websites such as pumppeelz.com have a custom sticker option available for each model of insulin pump where desired text can be added.
Alcohol swabs are a necessity for safe and sterile pumping. They can be prescribed or purchased over-the-counter.