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How Do I Program the Basal Rates for My Cortisol Pump?

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The beauty of the cortisol pump is that the basal rates are programmed specifically for each person based on their unique lab values. The very best thing you can do to ensure your success with the pump is to consult a medical provider that has successfully (key word) started and managed multiple pump patients.

If you cannot find an experienced doctor, your local doctor has the option of having an outside consultation with another provider that does have this level of experience.

The individualized rates are the whole reason for cortisol pumping.

If you are plugging in another person’s programmed rates, or a generic program without any testing or titrating, then this is not much better than using an oral steroid regimen.

For some pumpers, getting night time cortisol coverage is enough to make some improvement over how they were feeling on oral steroids. However, in order to see the full improvement, the rates must be tailored to the individual.

Basal Rate Programming Methods

NONE of the methods below should be attempted without a doctor. ALL methods will require follow up serial cortisol testing to assess adequacy of the basal program.

Generally, pumpers start with 4-8 daily infusion rates. (Hindmarsh, Geertsma 2017 p. 356) Time blocks might be divided as follows, 00-02, 02-04, 04-08, 08-12, 12-16, 16-19, 19-24. Often the pumper starts with a few time blocks and as rates are adjusted using serial cortisol testing, more time blocks may be created to fine tune the basal profile. The online steroid curve plotter tool may be used to visually plan time blocks and basal rates. The end result should resemble healthy circadian rhythm of cortisol.

Adjustments should be made based on ideal levels in normal people with an 8 am level around 20 mcg/dL (550 nmol/L) and a bedtime level around 2 mcg/dL (55nmol/L). Afternoon levels should be gradually decreasing in between these 2 measurements.

Clearance testing finds the rate at which an individual absorbs, distributes, metabolizes, and excretes hydrocortisone. This data can be used to calculate delivery rates needed to achieve the desired blood cortisol level.

Cortisol clearance testing should ideally be conducted first thing in the morning to minimize the time the individual has to go without hydrocortisone. The patient’s morning hydrocortisone dose will need to be withheld so it will not interfere with the test.

1. Place IV cannula and draw baseline cortisol.

2. Give IV bolus of 15 mg x body surface area (Charmandari et al 2001) solu-cortef and flush cannula well.

3. “Cortisol levels should be drawn every 5 minutes for the first 45 min, every 15 minutes for the next 45 minutes, every 30 minutes for the next 90 minutes.” (Hindmarsh, Geertsma 2017 p. 102) The patient should continue normal steroid dosing schedule for the rest of the day.

“Clearance was calculated following estimation of the area under the drug concentration vs. time curve (AUC) from time (t) 0 min to infinite time (inf.) as follows: CL = dose (iv)/AUC0-inf. (8, 9). The elimination rate constant (k) was calculated from the slope of the regression line of the log transformed cortisol data vs. time. The volume of distribution was estimated by dividing cortisol clearance by the elimination rate constant: V = CL/k (10). Finally, half-life (t1/2) was estimated by dividing 0.693 (loge2) by the elimination rate constant: t1/2 = 0.693/k (11). Half-life is a composite pharmacokinetic parameter determined by both clearance and volume of distribution (t1/2 = 0.693 × V/CL) and, therefore, it is increased by an increase in volume of distribution or a decrease in clearance and vice versa.”

(Charmandari, Hindmarsh, Johnston 2001)

Using clearance testing to calculate precise rates is generally the safest and most accurate way to find basal rates. However, it may not be a feasible method if the patient’s insurance will not cover the test or if there is not a capable facility in the area the individual can travel.

Alternatively, some researchers use an average starting dose of hydrocortisone (Nella, et al 2016). This average dose will need to be calculated using body surface area. Body surface area can be calculated here. Average starting daily dose would be average rate x body surface area (m2).

However, there is a wide range used in research studies and will vary from patient to patient, anywhere from 10mg/m2 to 20mg/m2 (Løvås, Husebye 2007). Generally, it is safer to start an individual on a dosage at, or slightly above their current oral hydrocortisone dosage. This reduces risk of potential adrenal crisis when transitioning.

Its much easier to reduce rates than it is to find out exactly where the rates need to be increased and by how much. Note that dosage should always be carefully considered on an individual basis taking into account pumper’s current cortisol dosage, symptoms, comorbidities, and daily schedule.

Note, that while this method may not require testing prior to pump set up or complicated mathematical formulas, it is not necessarily the “easy way” to set up the pump. This method will require more follow up testing, a longer adjustment period, and may potentially miss individuals who are rapid metabolizers (Nella, et al 2016).

Keep in mind that NO basal profile will be perfect from the start, and EVERY pumper will need follow up serial cortisol testing to assess and titrate the basal rates.

Find out more:

What Tests Help Determine if my Basal Rates are Adequate?


How Do I Use The Pump When I’m Sick?


Bryan, S. M., Honour, J. W., & Hindmarsh, P. C. (2009). Appendix of: Management of Altered Hydrocortisone Pharmacokinetics in a Boy with Congenital Adrenal Hyperplasia Using a Continuous Subcutaneous Hydrocortisone InfusionThe Journal of Clinical Endocrinology & Metabolism94(9), 3477–3480. doi: 10.1210/jc.2009-0630

Charmandari, E., Hindmarsh, P. C., Johnston, A., & Brook, C. G. D. (2001). Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency: Alterations in Cortisol Pharmacokinetics at Puberty. The Journal of Clinical Endocrinology & Metabolism86(6), 2701–2708. doi: 10.1210/jcem.86.6.7522

Charmandari, E. (2001). Congenital adrenal hyperplasia: management during critical illness. Archives of Disease in Childhood85(1), 26–28. doi: 10.1136/adc.85.1.26

Hindmarsh, P. C., & Geertsma, K. (2017). Congenital adrenal hyperplasia: a comprehensive guide. London: Elsevier/Academic Press.

Løvås Kristian, & Husebye, E. S. (2007). Continuous subcutaneous hydrocortisone infusion in Addison’s disease. European Journal of Endocrinology157(1), 109–112. doi: 10.1530/eje-07-0052

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 & Metabolism101(12), 4690–4698. doi: 10.1210/jc.2016-1916