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December 23, 2007

Insulin, Other Medications

Question from United Kingdom:

I've had type 1 for over 20 years, since early childhood. Last year, I was diagnosed with autoimmune hypophysitis and treated accordingly. Recent retesting has revealed the majority of hormone axes are currently in good shape, but I've been told I remain ACTH deficient and I'm continuing to take to steroid replacement. Although I'm on low dose steroids, they have a clear impact on my blood glucose control. When I don't take them, which I've tried for short periods, I'm able to cut my pump basal rates by 50 to 75%, (e.g., 2.0 units per hour to 0.4 units per hour) and generally feel better, although I suffer disabling headaches and visual disturbance both on and off steroids and am unsure how this may relate. My diabetes team and endocrinologist say the steroids cannot be having an impact on my blood glucose control, as they are a physiological replacement dose only. I understand that uncorrected cortisol deficiency leads to hypoglycaemia, but my doctors seem to believe it is this alone that allows me to cut my basals. In actual fact, I do not experience increased hypoglycaemia and the basals I am cutting back from are at ridiculous levels I've never encountered in many years of pump use. Is it possible that a divided dose of just 20 mg of hydrocortisone a day can lead to increased insulin needs and, if so, do you believe this could be reflective of no longer needing the steroid replacement? Additionally, no one has been able to give me a straight answer on whether I'm at risk for the hypophysitis returning/worsening, or if spontaneous recovery can be complete and absolute. In fact, I've been unable to get much information at all about this condition as it seems to be a diagnosis largely of exclusion. Are there any other causes for ACTH/pituitary hormone deficiencies that may spontaneously recover?


It is true that hypophysitis may return at a later time in life. It is more common in women and it is more common after pregnancy. Even though there is an increased relative risk, compared to the population, it is still absolutely low. It is also true that you can get by with lower doses of insulin if not taking steroids, even at physiologic replacement doses, but who would want to? The symptoms of adrenal insufficiency are bad enough that it isn’t really a good alternative. That 20 mg per day of hydrocortisone is still a low dose.