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In patients with adrenal insufficiency, subcutaneous hydrocortisone infusion is a suitable alternative to oral glucocorticoids. This is especially true in cases of poor absorption or rapid metabolization of oral steroids.
Poor Oral Absorption
Causes of poor oral absorption may be due to acute gastrointestinal illness, chronic illness of the GI system, conditions of the liver, genetic pre-disposition, and use of other medications.
Individuals with rapid metabolization and clearance of cortisol may report that their oral steroid doses do not last the full expected duration. Increasing dosage amounts only serves to oversaturate cortisol binding globulin and adds no length to the duration of dose. This only exacerbates Cushing’s like over replacement symptoms such as central weight gain, muscle wasting, elevated blood glucose, increased blood pressure, rounded face, bone loss, and striae.
Additionally, rapid metabolizers often experience both symptoms of over and under treatment of corticosteroids (Hindmarsh, Geertsma 2017).
Patients with poorly controlled adrenal insufficiency on oral corticosteroids tend to see the most improvement. This is when compared to individuals that report having good quality of life on oral corticosteroids (Gagliardi et al 2014).
The cortisol pump method has been used with success in management of both primary and secondary forms of adrenal insufficiency.
A Note on Fludrocortisone
Note that patients requiring mineralocorticoid replacement (fludrocortisone) will need to continue with oral mineralocorticoid replacement. This is indicated by sodium and plasma renin biochemical testing.
Find out more:
Gagliardi, L., Nenke, M. A., Thynne, T. R. J., Borch, J. V. D., Rankin, W. A., Henley, D. E., … Torpy, D. J. (2014). Continuous Subcutaneous Hydrocortisone Infusion Therapy in Addisons Disease: A Randomized, Placebo-Controlled Clinical Trial. The Journal of Clinical Endocrinology & Metabolism, 99(11), 4149–4157. doi: 10.1210/jc.2014-2433
Hindmarsh, P. C., & Geertsma, K. (2017). Congenital adrenal hyperplasia: a comprehensive guide. London: Elsevier/Academic Press.