Insulin Pump for Hydrocortisone Delivery

Fall 2006 CARES Foundation, Inc.

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Insulin Pump for Hydrocortisone Delivery?

Peter Hindmarsh, M.D.


CAH is a challenge to manage, as the current medications available (hydrocortisone, prednisone and dexamethasone) cannot mimic easily the normal circadian rhythm of cortisol in the circulation. This problem arises because of the way in which these medications are administered, so that inevitably there are periods of over, normal and under exposure to the glucocorticoid during the 24-hour period. The critical time period for glucocorticoid exposure is from midnight through to the late afternoon, when theACTH drive from the pituitary is at its maximum. With the exception, perhaps, of dexamethasone, it is not easy to deliver glucocorticoid in a way in which ACTH suppression can easily be achieved, as this would, in many instances, require dosing after midnight in order for suppression to last through to the next morning. The situation can worsen during puberty when the clearance of hydrocortisone from the circulation is increased, necessitating more frequent hydrocortisone dosing. As the basic principle of endocrine therapy is to deliver replacement therapies in as physiological a manner as is possible, consideration needs to be given as to how this might be achieved. Two options are available. One is to modify the properties of hydrocortisone tablets into a slow release preparation. The other is to use other technologies to deliver hydrocortisone. The latter is what we have done recently in someone who cleared hydrocortisone very quickly. We used an insulin pump system to deliver small amounts of hydrocortisone, with variable amounts programmed in on an hour-by-hour basis, so that we could mimic the normal circadian rhythm and get good control of the CAH in terms of 17-OHP and androgen concentrations. While this approach of wearing a pump and delivering the hydrocortisone subcutaneously may not appeal to everyone, it is certainly worth thinking about in situations where hydrocortisone drug delivery is difficult.

The experience of a CAH-affected individual with this method of hydrocortisone delivery can be found on our Personal Stories page.

Peter Hindmarsh BSc, MBBS, MD, RCP, FRCPCH is a Paediatric Endocrinologist specializing in Adrenal Diseases and Diabetes at the Great Ormond Street Hospital in London, UK. He has notified CARES that he will advise any physician wishing to try the pump for his or her patient.

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