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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.
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:
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 Infusion. The Journal of Clinical Endocrinology & Metabolism, 94(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 & Metabolism, 86(6), 2701–2708. doi: 10.1210/jcem.86.6.7522
Charmandari, E. (2001). Congenital adrenal hyperplasia: management during critical illness. Archives of Disease in Childhood, 85(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 Endocrinology, 157(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 & Metabolism, 101(12), 4690–4698. doi: 10.1210/jc.2016-1916