The Cortisol Pump

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Troubleshooting

If managed correctly, problems with the pump are generally rare. However, when problems do arise, they can be incredibly frustrating. Below are some tips for troubleshooting the cortisol pump.

Please do not be discouraged! There are pumpers out there that have already encountered these problems and found solutions.

There are few potential causes for red itchy bumps at the infusion site, and in some cases, it may be difficult to tell which is the culprit.

One possibility, though rare, could be an allergic reaction. In cases where allergy is truly the cause, it most often is an allergy to the inset adhesive. Fortunately, there are many ways to work around an adhesive allergy. Some solutions will work better for some individuals than others.

For some pumpers, all that is needed is a barrier wipe or spray. This is applied to the skin after cleaning and disinfecting the area, and right before applying the inset. There are many brands of barrier wipes and sprays available to try. They have the added bonus of helping the adhesive stick more securely.

Another option would be a film barrier such as IV3000 or Tegaderm. This might seem counter intuitive to add another adhesive product to the skin, but these dressings are designed for hospital use and are made with sensitive skin in mind. Film barriers are applied after cleaning and disinfecting the area. Be sure to allow the area to dry completely and then apply the barrier film. The inset is applied on top of the barrier film and the cannula will punch right through it.

There are also a couple lesser known solutions that have been reported to work for adhesive allergy. These have been utilized by the insulin pump community for some time, and work equally well for cortisol pumpers.

Flonase nasal spray. Yes, the allergy nose spray. The active ingredient in Flonase is fluticasone propionate, which is a steroid. This provides topical, non systemic, relief of swelling, redness and itching. The spray should be applied after cleaning and disinfecting the area. Allow the spray to dry then apply the inset.

Another seemingly odd solution is deodorant. Yes, the regular stick deodorant, but please do not use the same stick you use under your arms as this could transfer bacteria. As strange as it sounds, the deodorant stick or spray (not gel) works as a skin barrier. It also has the added bonus of keeping the area nice and dry so it is less likely to sweat off. Unscented deodorant is recommended. Do not use if you have a known allergy to any ingredient in the deodorant.

With some trial and error, pumpers can almost always find a work around for adhesive allergies. Some times it takes experiementing with combinations of the above products or it may be a specific brand of product that works best.

In some, even more rare cases, the Teflon cannula itself is the cause of the allergy. If that is the cause, tubed pumps have a steel cannula option you can order. However, this is not an option for Omnimpod.

Insufficient basal rates are the most common cause of site irritation among cortisol pumpers. This is another reason why follow up testing with serial cortisol labs is so important. It’s not only the total basal amount that needs consideration, but each and every individual time block that needs to be titrated exactly for each pumper’s needs.

Unfortunately, this is commonly mistaken as a skin allergy, and the following scenario is all to common: pumper is started on a generic, “cookie cutter” basal profile not tailored for them. Pumper also does not have adequate, or in many cases, ANY follow up testing. Pumper experiences red itchy welts at the site, and pumper and/or doctor assume it’s an allergy. Pumper tries various allergy solutions to no avail. Pumper and doctor assume it’s a cannula allergy. Pumper tries steel cannulas, but they are still reacting. Doctor and pumper assume its an allergy to the Solu-Cortef itself and give up the pump, going back to previous, sub-par quality of life on oral steroids.

This entire scenario could have been prevented by proper testing and adjusting of the pumper’s basal rates. See topic “How Do I Know If My Basal Rates Are Adequate?” Keep in mind, the goal for basal rates should be a healthy circadian rhythm like that of a non-adrenal sufficient individuals, not just “in range” values.

As addressed in a previous topic- “Powder Vials vs. Act-o-vials”, there are pH discrepancies with the Act-o-vials in the US. The pH has been tested to be consistently lower than what is stated on the packaging, however Pfizer is still looking into this. This has caused skin reactions in some pumpers. For individiuals with pH sensitivities, it may help to switch from Act-o-vials to the plain powder 100mg Solu-Cortef vials.

A red itchy site could also be a very early sign of infection. If an infection is suspected, the infusion set should be removed right away. The inset, tubing, reservoir and Solu-Cortef should be discarded and not reused. A new reservoir must be filled and a new inset and tubing must be used in a different location, away from the affected area.

Skin reactions typically improve and do not worsen once the inset is removed. However, an infection will usually grow in size, the area will become more painful and there will be increased swelling, and redness.

Anytime a site looks WORSE after removal, that is a good clue that it is probably an infection. If you believe your site is infected, draw around the outside of the red area with a Sharpie. If the area gets bigger, grows outside the area you have marked, you need to seek medical attention for the infection. Please see the section “What Are Some Risks of the Cortisol Pump?” for more information about site infections.

Pump bumps are well known in the diabetic community and happen most commonly to people using insulin injections. These bumps may be caused by lipohypertrophy (Barola, et al 2018). Pump bumps are harmless though they can be annoying.

Pump bumps are known to somewhat inhibit the absorption of insulin, and from the anecdotal experiences of cortisol pumpers, it would seem this thickened tissue also hinders absorption of hydrocortisone as well. The absorption seems to decline the longer the cannula is left in the affected area. If you feel a lump at your infusion site, remove the cannula and start a new infusion site in a different location.

The more volume that is pumped through an infusion site and the more often an infusion site is used, the higher the probability of encountering a pump bump. This is yet another reason to rotate infusion sites and never use an inset longer than three days. Pump bumps do not usually require medical attention and will heal on their own. However they do tend to heal very slowly, sometimes taking weeks or months to fully heal. Avoid using this area until the lump is gone.

This is commonly referred to as a bleeder. Bleeders are caused by the cannula accidentally hitting a vein or the cannula damaging tiny capillaries under the skin. Knocking or bumping the infusion site can increase the chances of encountering a bleeder. Sometimes they seem to bleed an awful lot for such a tiny hole, but they are harmless. Bleeders do not require medical attention, but can be a mess to clean up.

Bleeders can sometimes be detected by bruising around the infusion site. Often this bruised area will not absorb hydrocortisone as well, and you might feel slightly “off” (fatigued, headache, etc.). It is a good idea to change your infusion set anytime you notice bruising.

With some experience, you can learn to be prepared for bleeders. If you notice bruising around the infusion site, blood in the cannula, red or dark dried blood around the adhesive, then you may have a bleeder to deal with.

You should always have a clean absorbent cloth, paper towels, or gauze handy when removing an inset. Also, you should have alcohol wipes to clean up any blood remaining on the skin, and a small adhesive bandage to place over the hole left by the cannula. Some pumpers also like to use an antibiotic ointment such as Neosporin on the hole left by the cannula before placing the adhesive bandage over it.

If your insets are not sticking well, or seem to fall off before you’re ready for a site change, don’t worry, there are endless solutions to help your inset stick.

Always make sure your skin is clean and dry before applying your inset. When using alcohol wipes, be sure the area has dried completely prior to inserting your inset. Try to avoid getting the inset wet or sweaty for the first hour after application.

Skin prep products, such as Skin tac are one option to help your inset stick to your skin. Some pumpers swear by deodorant to keep their insets dry and sticking. (Use a new deodorant stick, and not the same one you use under your arms. This is important so you should use something like a Sharpie to write on the one you will use for skin prep so that you can identify it for this use only.)

When using skin preps or adhesive grips, it is a good idea to have adhesive remover handy. The extra stick may be difficult and or painful to remove when it comes time to change the site. Adhesive remover makes this a much smoother experience.

Adhesive dressings are another option to help keep your site in place. Products such as GrifGrips, Simpatch and Pump Peelz make tapes and patches to extend the wear of insets. Many options come in colorful designs or shapes, making this a fun problem to solve.

When using skin preps or adhesive grips, it is a good idea to have adhesive remover handy. The extra stick may be difficult and or painful to remove when it comes time to change the site. Adhesive remover makes this a much smoother experience.

Are you not falling asleep or waking up at the wrong times? Your basal program probably needs adjustments.

Both too much or too little cortisol can cause sleeplessness, making this a particularly challenging problem to solve. This is another reason having a 24 hour cortisol profile is a big advantage.

With 24 hour testing you will know exactly what your blood cortisol levels are from hour to hour so it is much easier to make accurate adjustments to the basal program that will allow you to get a good night’s sleep.

Please see the section “How Do I Know If My Basal Rates Are Adequate?” for more information.

If after starting on the cortisol pump you’re still dealing with daytime fatigue, it’s likely your basal program needs adjusting. Serial cortisol testing can provide the data needed to titrate your rates. In most cases it takes several rounds of serial cortisol testing to get the basal program set correctly.

Basal rates need to be checked periodically against serial lab work (at least once per year is suggested, or more frequently until the patient feels their best) in order to ensure they are still adequate. An individual’s cortisol requirement may increase or decrease over time depending on age, body mass, or other medications being taken.

Close attention needs to be paid to the early morning and AM peak cortisol levels. The pump is not like pills, the rates build on each other. Often in cases of daytime fatigue, the early morning basal rates are too low and consequently the AM peak does not reach an optimal level.

In some cases, the basal is programmed in such a way that the peak doesn’t occur until later in the day. Not only does this situation cause some over replacement, but as the entire day plays off of the AM peak, it is crucial to achieve the right level at the right time.

Please see the section “How Do I Know If My Basal Rates Are Adequate?” for more information.

Pumpers with non-conventional schedules, such as night shift workers, may need their peak time adjusted accordingly.

Sources

Barola, A., Tiwari, P., Bhansali, A., Grover, S., & Dayal, D. (2018). Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma? Frontiers in Endocrinology, 9. doi: 10.3389/fendo.2018.00638