What are Some Risks of a Cortisol Pump?

21 Nov, 2019 What to Expect 0

Subcutaneous hydrocortisone infusion has been shown in studies to be “a safe and well-tolerated modality of cortisol replacement” (Nella et al 2016). Additionally, it is viewed as “a safe and reliable mode of glucocorticoid replacement and thus an attractive treatment option in selected patients” (Øksnes et al 2014). However no treatment is without any risk.

Below, we shall explore some of the more common risks associated with using a cortisol pump.

Cortisol pumping is a little more forgiving than insulin pumping as the risk of overdose, unlike with insulin, is virtually nonexistent. Excess cortisol is simply excreted via urine. However, over and under treatment are still concerns, just as they are with oral corticosteroid regimens.

Follow sterile techniques when filling the pump and starting or removing an infusion site.

As with insulin pumps, cortisol pumps also have a potential risk for site infections. Fortunately, infections are preventable by following sterile techniques when filling the pump and starting or removing an infusion site.

Before starting or removing a site, always wash your hands thoroughly. The infusion area should be cleansed and prepped with an alcohol wipe. The tops of the vials used to fill the pump’s cartridge should be wiped with an alcohol pad.

Removing an inset should also be a sterile process. Individuals should use care to keep previous infusion sites clean until they are completely healed (which usually happens quickly). They may choose to cover the site with a small adhesive bandage and topical antibiotic ointment. For those prone to infections, they may consider using antiseptic products such as Hibicleans (Chlorhexidine gluconate 4%).

Signs of Infection

Early signs of infusion site infection might include itching, redness and tenderness at the infusion site (Cellulitis, Mayoclinic.org). If experiencing any of these sympoms, immediately remove the infusion set. Discard the inset, cartridge, and tubing. Do not try to reuse the hydrocortisone from the cartridge.

Topical antibiotic ointment may help if the infection is caught very early. In cases of infection, the redness and swelling may continue to spread after the infusion set is removed. Growing redness and swelling despite removal of cannula, are signs that this is, in fact, an infection and not a case contact dermatitis such as with adhesive allergy.

If the area worsens after removing the site, patients should make a doctor’s appointment ASAP as an oral antibiotic is usually required.

Site infections should not be ignored.

The longer they are allowed to spread, the harder they will be to treat, and the longer they will take to heal. Patients should avoid infusing in or near the affected area until it has completely healed (Insulin Pumps and Infections, Diabetesforcast.org).

“When in doubt, change it out!”

Infusion site failure is another risk with subcutaneous infusion. A cannula might become bent upon insertion or with repeated bumping. A site may hit muscle tissue and bruise, or bleed hindering absorption. Sites may sweat or rub off. They may accidentally become snagged and pulled out. Leakage may also occur due to placement or movement of the site.

All of these situations may limit or block flow/absorption of medication. However, none of these situations are serious if handled timely. Patients should visually inspect the infusion site regularly for signs of bruising, bleeding, or leaking. Bleeding may be very slight, and may sometimes appear as a small amount of blood in the cannula. Leaking can be spotted by discoloration of the site adhesive.

If you notice these signs, you are not getting the full dosage of hydrocortisone. The infusion set will need to be changed.

Site issues such as these will not “fix themselves” and should not be ignored. The sooner the problem is corrected the better the outcome will be.

In cases of bent cannula, there are often no external signs. Usually the problem is unnoticed until the individual starts experiencing low cortisol symptoms, such as fatigue, headache, nausea, loss of appetite, etc. The trouble in this situation is that pumpers often disregard these symptoms as normal adrenal insufficiency related side effects of stress or may theorize that symptoms are due to an illness.

If these symptoms arise usually the next step would be to administer a bolus. If the symptoms do not resolve, then it is probable the cannula is blocked and the inset should be changed immediately. Cortisol pumpers should remember the saying, “When in doubt, change it out!”

Always have a backup treatment plan.

Pump failure is a very uncommon risk. Modern insulin pumps have improved dramatically over the years and adverse incidents due to pump failure have decreased since the 80s and 90s. There are alarms any time the pump is unable to deliver medication.

Even so, it’s a good idea to develop a backup plan for cortisol replacement such as oral steroids or subcutaneous injections as a precaution. Doctors should ensure the pumper has the medication(s) and/or supplies needed to implement the back up plan if it becomes necessary.

When traveling internationally, you are able to request a Travel Loaner Pump as an additional method of precaution. For Medtronic, this is done through their website. If you use an OmniPod, contact your local rep. Be sure to have your basal rates recorded, as the loaner pump will not have that information saved.

Practice good site rotation techniques.

Scarring and subcutaneous atrophy are uncommon and easily preventable risks. Scarring of the skin can be avoided by rotating infusion sites, and changing the infusion set promptly every 3 days. Rotating means utilizing different areas of the body instead of repeatedly using one area.

Different pumps models are tested for use on different areas, but generally speaking, sites can be used on the abdomen, backs of the arms, subcutaneous tissue in the lower back/upper buttock, and legs. Patients will find that they prefer certain areas to others and may have better results in specific areas of the body.

As tempting as it may be to use a well performing site repeatedly, its best to alternate to other areas to allow the skin and subcutaneous tissue to “rest”.

Find out more:

How do I Get a Cortisol Pump?

What are Some Common Cortisol Pump Misconceptions?

Troubleshooting

Sources

Cellulitis. (2018, April 10). Retrieved from https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-causes/syc-20370762.

Insulin Pumps and Infections. (n.d.). Retrieved from http://www.diabetesforecast.org/2008/jan/insulin-pumps-and-infections.html.

Øksnes, M., Björnsdottir, S., Isaksson, M., Methlie, P., Carlsen, S., Nilsen, R. M., … Løvås, K. (2014). Continuous Subcutaneous Hydrocortisone Infusion versus Oral Hydrocortisone Replacement for Treatment of Addisons Disease: A Randomized Clinical Trial. The Journal of Clinical Endocrinology & Metabolism, 99(5), 1665–1674. doi: 10.1210/jc.2013-4253

Nella, A. A., Mallappa, A., Perritt, A. F., Gounden, V., Kumar, P., Sinaii, N., … Merke, D. P. (2016). A Phase 2 Study of Continuous Subcutaneous Hydrocortisone Infusion in Adults With Congenital Adrenal Hyperplasia. The Journal of Clinical Endocrinology & Metabolism, 101(12), 4690–4698. doi: 10.1210/jc.2016-1916

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