Managing Adrenal Insufficiency with the Cortisol Pump

Managing Adrenal Insufficiency with the Cortisol Pump

Citation: Adrenal Alternatives Foundation

Adrenal Insufficiency and Diabetes are both difficult diseases to manage and the Adrenal Alternatives Foundation sympathizes with T1D and T2D patients. Both are serious, endocrine disorders and we are in no way downplaying the battle of diabetic patients, we are simply using it as a comparative tool to explain adrenal disease, as most people are unaware of it.

Adrenal insufficiency is a disease where the adrenal glands fail to produce the proper amounts of steroid hormones. There are many different forms of adrenal disease, but the treatment for all forms is the same- steroids for cortisol replacement.

Type 1 Diabetes is the disease where the pancreas fails to produce the correct amount of insulin, thus rendering someone insulin dependent. Both of these diseases are endocrine disorders. Both of these diseases require life-long replacement therapy. The adrenal insufficient person is dependent on cortisol. The diabetic is dependent on insulin. Both of these diseases are life threatening. Both of these diseases require daily monitoring.

Almost every cell in the body has cortisol receptors, making it a crucial hormone. This hormone impacts multiple functions of the body. Without adequate levels of cortisol, the body will go into an adrenal crisis which will result in organ failure and eventually death. Cortisol impacts blood sugar levels, metabolism, stress response, inflammation levels, aids in the immune system, affects the metabolic processes such as the salt and water balances within the body and it also greatly impacts the circadian rhythm.

Unlike diabetic patients, adrenal disease sufferers have no meter to check their cortisol levels. They must be constantly vigilant of their own personal signs and symptoms of low cortisol. and require an emergency injection if their levels drop too low. The standard treatment for all adrenal disease patients is daily cortisol replacement medication- steroids.

Medications such as prednisone, dexamethasone or hydrocortisone are prescribed to replace the deficits of steroid hormones in the body. Steroids have a myriad of side effects ranging from weight gain to emotional disturbances. Long term steroid use has been linked to damage of the bones, eyesight and even muscle tissue.  Yet, steroid cortisol replacement is the only treatment for adrenal disease. In a normal person, during situations of emotional or physical stress their body releases more cortisol. The excitement from a happy event, the sadness from a death of a loved one or the strain from exercising are examples of things that would cause the body to release more cortisol. In an adrenal insufficient person, this does not happen. They have to artificially manage their cortisol. Their personal cortisol needs may differ from day to day. No two days are the same and it is a struggle to regulate proper cortisol levels.

The most commonly prescribed steroid for adrenal insufficiency is hydrocortisone (HC). This is the bio-identical steroid medication. This medication has a blood serum half life of 90 minutes and must be taken multiple times a day. Most adrenal patients struggle with quality of life due to this mismanagement. Oral HC must be processed through the stomach and the liver before reaching the blood stream.  This causes a constant rise and fall of cortisol levels, which results in subpar function, increases mortality rates and decreases quality of life.

 

Below is an example of natural circadian cortisol rhythm without the presence of adrenal disease-

naturalCircadian

 

The chart below is the circadian rhythm of an adrenal patient on oral hydrocortisone replacement.

UnnaturalCircadian

This image was created with Clearly Alive’s Theoretical Steroid Dose Plotter

Quality of life in adrenal disease patients is vastly poor due to this lack of balance. Oral cortisol replacement cannot do what natural cortisol can. But fortunately, endocrinology research has found a solution for adrenal patients who have failed to stabilize on oral cortisol replacement medications. The concept of Cortisol Pumping is the use of solu-cortef (inject-able version of cortisol when mixed with saline) used in an insulin pump programmed to disperse cortisol according to the natural circadian rhythm by programming rates of delivery into the pump. This therapy bypasses the gastric passage and is able to deliver cortisol in a more natural way. With this method, an adrenal insufficient patient can receive a constant supply of cortisol and will not suffer the instability experienced with oral steroid cortisol replacement. Side effects due to mal-absorption are decreased and patients have been reported to have improved sleep, weight management and experience an overall improvement in their energy levels and sense of well-being. This method has also been proven to lessen the prevalence of adrenal crises and lessen hospitalizations due to low cortisol.

Peter Hindmarsh, Professor of Paediatric Endocrinology at University College London and Consultant in Paediatric Endocrinology and Diabetes at University College London Hospitals and Great Ormond Street Hospital for Children. He is currently Divisional Clinical Director for Paediatrics at University College London Hospitals is a pioneer for the cortisol infusion method. He has done much international research and has proven that this method improves the lives of adrenal insufficient patients.

Though this method is not a cure for adrenal disease, it is an option and a ray of hope for those who are struggling with quality of life.

PumpAware

 

 

Sources:

 

Chauhan. Adrenal Insufficiency: Burden Of Disease And Cost Of Illness. http://www.ispor.org/research_pdfs/45/pdffiles/PDB30.pdf. Accessed May 22, 2016.

Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. Jama. 2002;287(2):236-240.

Daniel E, Newell-Price J. THERAPY OF ENDOCRINE DISEASE: Steroidogenesis enzyme inhibitors in Cushing’s syndrome. Eur J Endocrinol. 2015.

Gagliardi L, Nenke MA, Thynne TR, von der Borch J, Rankin WA, Henley DE, Sorbello J, Inder WJ, Torpy DJ. Continuous subcutaneous hydrocortisone infusion therapy in Addison’s disease: a randomized, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2014;99(11):4149-4157.

Hindmarsh PC, Charmandari E. Variation in Absorption and Half-life of Hydrocortisone Influence Plasma Cortisol Concentrations. Clin Endocrinol (Oxf). 2015; 82: 557-61.

Oksnes M, Bjornsdottir S, Isaksson M, Methlie P, Carlsen S, Nilsen RM, Broman JE, Triebner K, Kampe O, Hulting AL, Bensing S, Husebye ES, Lovas K. Continuous subcutaneous hydrocortisone infusion versus oral hydrocortisone replacement for treatment of addison’s disease: a randomized clinical trial. J Clin Endocrinol Metab. 2014;99(5):1665-1674.

 

Copyright © *2019 Adrenal Alternatives Foundation* All rights reserved. Adrenal Alternatives Foundation is a patient empowerment organization that encourages, educates and advocates for sufferers of all adrenal diseases and is registered with the IRS as a 501(c)3 nonprofit organization.

 

 

Sarah’s Success with the Cortisol Pump

A personal testimony of Sarah’s story with the cortisol pump.

 

When a person’s liver goes bad, they can get on a transplant list for a new organ. When their heart or lungs give out, they have the same possible options. When a diabetic reaches a certain level of instability, they’re offered another alternative, a continuous infusion pump for insulin.

When a person’s adrenal glands stop working, there is no transplant, or medical miracle. For many, it’s a pill 3-5 times a day, and they can get back to life as usual for the most part.

For some of us, though, the oral steroids don’t work. Sometimes it’s a malabsorption issue. Sometimes it’s a rapid metabolism issue. Sometimes it’s gastroparesis (slow stomach processing) or rapid gastric emptying. Sometimes we don’t understand the cause, just that oral steroids keep us alive, but quite unwell.

That was the case for me. 

I took oral hydrocortisone, split into 6 daily doses for a total of 25 mg when I was first diagnosed. I saw very little improvement, and was still experiencing low cortisol symptoms regularly. We tried increasing my dose to 35mg daily total, with no improvement. 

I was in the ER at least once a month! My favorite Adrenal Disease Support Group was filled with members who had experienced similar lack of improvement with oral steroids. They tried Prednisone, dexamethasone, sometimes specially compounded or extended release hydrocortisone as available in their countries, but each had the same result.

The oral medication just wasn’t working.

I asked my Endocrinologist if we could consider trying subcutaneous dosing of the solumedrol I had on hand for my emergency injection. Though, I’ll be honest, I tried it myself for two weeks prior to my appointment so that I could approach my doctor with evidence that it had changed things for me.

I was lucky my doctor wasn’t upset with me for trying something without talking to him first. I definitely recommend discussing your treatment with your doctor first, for your own safety!

He was, however, impressed that I was actively trying to find a better solution for managing my health.During this appointment, we discussed how much better I felt, even though I was still requiring 6 doses a day. That meant 6 injections a day, including throughout the night. Solumedrol is a longer acting steroid, so I should have been able to dose every 6-8 hours, but for reasons we still don’t know, I needed it every 4 hours.

My doctor recommended that we try oral Prednisone and oral dexamethasone first to be sure that neither would work for me, and over the course of the next few weeks we realized that not only did Prednisone not work for me, but it made me so agitated and angry that the Hulk looked like a sweet kitten…

Dexamethasone was much better for my demeanor, and I felt great for about 6 hours, but it’s supposed to last for 24! Ultimately, we decided that the subcutaneous injections were necessary, and we started the conversation about using a continuous infusion pump so that I could get some sleep!

During the next 5 months, I was still finding myself in the ER for fluids and IV hydrocortisone at least once a month. We were looking into the logistics of a modified infusion pump, as use for cortisol instead of insulin is “off label” and not typically covered by insurance.

Though there are an increasing number of studies about how beneficial continuous hydrocortisone infusion is for the life expectancy and quality of life for AI patients (see links at the end of this post), insurance companies and even most endocrinologists are hesitant to use them. Mine, a top endocrinologist in the country, had never heard of it before.

I gathered research for him, and we talked at length about the benefits and risks. By December, I’d found an extra pump and supplies, and was ready to get started. I had a procedure in the hospital, due to my chronically crappy veins I had a port-a-cath implanted, which resulted in a longer stay. They accidentally punctured my lung!

While in the hospital, they gave me IV boluses of hydrocortisone every 6 hours. They were trying to figure out why my blood pressure was crashing, and why I was not stabilizing.The doctor and I chatted about my need for continuous infusion, and by day 4 in the hospital, he had agreed to put the solucortef directly into the saline bag instead of the every 6 hour bolus.The change was immediate. My blood pressure stabilized, I was able to get up and move around the room again, and by day 6, I was ready to go home.We immediately finished getting the infusion pump set up with my local doctor (who is amazing and was with us through the process and discussion as well).This was six months ago.

Since the beginning of my continuous infusion, I have been to the ER twice. Both times due to norovirus and dehydration, though my cortisol was still very well managed at home.

This new “artificial adrenal gland” was an epic adjustment to my quality of life. I have gone from dozens of ER visits by this time last year, to two total this year. I have been able to teach a small community education class (I can manage about 2-3 hours a couple days a week for about two weeks at time now, where I couldn’t before!) I can go to Walmart and not need the electric wheelchair. I can walk around the block. I’m averaging 4-5 thousand steps a day now, instead of 1-2 thousand.

Am I back to “normal”? Nope. But my new normal looks a hell of a lot better now.

For more research regarding the infusion pump for cortisol check out my collection on Google Drive: Cortisol Pump Research

 

What is the Cortisol Pump?

whatcortisolpump (2).jpg

What is the cortisol pump?

Basically, the cortisol pump is a repurposed insulin pump that delivers solu-cortef instead of insulin.

The use of solu-cortef (injectable version of cortisol when mixed with saline) is placed in an insulin pump that is programmed to disperse cortisol according to circadian rhythm dosing by programming rates of basal delivery into the pump. The pump also has options to bolus for stress dosing.

This helps adrenal patients maintain better control of their cortisol levels by allowing them to get cortisol quicker instead of waiting until steroid pills metabolize through the stomach and finally enter the bloodstream.

This therapy bypasses the gastric system and is able to deliver cortisol in a more consistent way. With a pump, an adrenal insufficient patient can receive a constant supply of cortisol and will not suffer the ups and downs with oral cortisol replacement tablets. They are able to sleep through the night without having to wake up to take steroid pills.

This can be of great benefit to adrenal patients who are hypermetabolizers of cortisol. Some patients have to take medications more frequently than others due to their body’s high cortisol clearance rate. The pump is a great asset to these patients because they are no longer forced to take pills every couple of hours around the clock.

Side effects due to mal-absorption can be decreased and patients have been reported to have improved sleep, weight management, gastric issues and experience an overall improvement in their energy levels and sense of well-being as opposed to taking steroid tablets.

Professor Hindmarsh, of CAHISUS is a pioneer for this life changing treatment.

For more information on the medical information visit his website-http://www.cahisus.co.uk/pdf/USING%20THE%20PUMP%20METHOD%20IN%20ADDISON%27S.pdf

The pump is not a cure for adrenal disease and is difficult to obtain. This treatment is relatively an unknown in the United States and this foundation is actively working to raise awareness on this alternative treatment to managing adrenal insufficiency.

It is a difficult process but it IS POSSIBLE!  For more information please read our article on HOW TO GET ON THE CORTISOL PUMP.

If you feel you could benefit from the cortisol pump, speak with your endocrinologist but be prepared to hear “NO.”

Don’t lose heart!

There are doctors in the USA who will manage this treatment and we hope to continue raising awareness so that one day it will be as available to adrenal patients as it is to diabetics.

We’re here to lead all adrenal patients to every adrenal alternative!

 

 

 

 

 

HOW TO GET ON THE CORTISOL PUMP

 

 

HOW TO GET ON THE CORTISOL PUMP-

Step 1- Assess your life, health and disease management.

The cortisol pump is not a cure for adrenal insufficiency and is not a treatment that is right for everyone. If you are well managed on the steroid replacement pills, the adrenal pump is excess money and effort you may not need.

The pump is NOT an easy thing to acquire and the fight to get one takes a great deal of trouble, mental stamina and resources.

You need to consider whether this is something you actually need or not.

Here is a link to a wonderful post about 5 reasons NOT to get a cortisol pump by a lovely woman who has adrenal insufficiency and is on the pump. Reasons NOT to Get a Cortisol Pump

That being said, If you are struggling with your quality of life this treatment may help you.

Step 2- Research, Learn and Educate for yourself!

Adrenal insufficiency is a rare disease not widely understood in the medical community. You need to become an expert on your own health, especially if you are attempting to get on the pump.

Most doctors barely know anything about adrenal disease. They have been taught that replacement therapy with pills is the only treatment and that patients live a normal life with this disease.

Nothing could be further from the truth.

You need to understand your specific health concerns.

Information you need to know-

What is your diagnosis? Do you have primary Addison’s disease, secondary adrenal insufficiency, tertiary adrenal insufficiency or congenital adrenal hyperplasia?

If you are unsure, here is a link to Understanding Adrenal Disease

What is your quality of life? Are you able to work, drive, do housework or function normally?

What have you tried to manage your adrenal disease?

Typically an endocrinologist will not even consider the pump until you have tried EVERY oral steroid possible.

What is your current daily dose of replacement steroid?

How much are you stress dosing?

What other medical issues do you have?

Are you able to afford the supplies and medication needed for the pump? Insurance does not typically cover “off label” treatments.

 

This disease is expensive and life threatening if left untreated. If you have A.I you HAVE to have some sort of steroid replacement to stay alive.

Just educate yourself on everything you need to know. You will have to present YOUR case to an endocrinologist to get the cortisol pump. Which brings us to the next point.

Step 3- Finding An Endocrinologist

This will be a difficult part of your journey to the pump. Finding an endocrinologist that understands adrenal insufficiency is a needle in a haystack and then finding one who will be brave enough to attempt guiding you through pump therapy just adds to the challenge.

Prepare the best case possible. Send your research, your health information, everything you can to the endocrinologist BEFORE your appointment so they are aware of your intentions before hand. Write a letter to the endocrinologist explaining diagnosis, failed treatments and desire to be on the pump.

You will have to fight to find a doctor willing to write the script for the pump. It will take effort, lots of research and a mental stamina.

Step 4- Battling the Insurance Company

Adrenal Insufficiency is documented to be treated by oral steroids and not by the insulin pump. Be prepared to be on the phone for hours and be told incorrect information. Just be aware that you will have to tell the same story to a different agent over and over and over again. Don’t give up.

 

Step 5- Getting A Pump & Supplies

If your insurance cooperates and provides you with a pump and supplies, GREAT! But I’m pretty sure with A.I it won’t be that easy.

Take heart, there are other options.

There are many ways to obtain a pump and supplies: Diabetic Barter Sites, Facebook Groups, Craigslist and Ebay.

The internet is a plethora of connectivity. You can find what you need, you just have to put in the effort to look.

Step 6- Waiting for the Pump

If you are not doing well on pills, switching to subcutaneous injections of solu-cortef may be an option while you are waiting.

To figure out your dose, You need to convert it from oral milligrams to liquid solu-cortef.

2 units= 1mg if you are doing a 2:1 ratio with actovials of solucortef.

You can also run a 1:1 ratio with 1ML of saline per 100mg of solucortef powder vials.

You also need to dose according to the circadian rhythm percentages.

Circadian dosing method example-

6am and 12 noon 40%

12 and 6pm 20 %

6pm to Midnight 10-15%

Midnight and 6am 25-35%

Source for the dosing is based on Professor Hindmarsh’s research (link posted below)

Click to access CIRCADIAN%20RHYTHM%20DOSING.pdf

Use solu cortef solution and inject with insulin needles.

The standard recommendation is to have lab testing to see how quickly you absorb and “use” the cortisol in your body.

You can have cortisol clearance testing done but it is not typically covered by insurance. It is beneficial to creating proper rates for your specific needs. A pump is only as good as the information programmed into it.

Step 7- Staying Sane

The process to get on the pump is long, obnoxious and detailed. No one should have to fight for years to get better quality of life. The healthcare system is broken and changes need to made. This stands for all diseases and treatments, not just adrenal disease.

Everyone should have access to a better life.

Take heart friends, Our voices will be heard.

This foundation is dedicated to adrenal disease advocacy.