Hydrocortisone

# Hydrocortisone ## Overview - **Classification**: Corticosteroid (glucocorticoid) - **Mechanism**: Binds to intracellular glucocorticoid receptors, modulating gene expression; decreases inflammation and suppresses immune response; replaces endogenous cortisol in adrenal insufficiency. ## Primary Indications 1. **Adrenal Insufficiency**: Replacement therapy. 2. **Anti-inflammatory/Immunosuppressive**: Allergic reactions, asthma, inflammatory bowel disease, dermatologic conditions, rheumatic disorders. 3. **Septic Shock**: Adjunctive therapy for patients with refractory hypotension. ## Adult Dosing ### Standard Dosing **Adrenal Insufficiency (Physiologic Replacement)** - **Dose**: **15-25 mg** total daily dose. - **Frequency**: Divided **BID or TID** (e.g., 10-15 mg AM, 5-10 mg PM). - **Route**: Oral. - **Duration**: Chronic. **Adrenal Crisis (Acute)** - **Dose**: **100 mg** IV bolus. - **Frequency**: Followed by **100 mg** IV every **8 hours** or continuous infusion. - **Route**: IV. - **Special Considerations**: Rapid taper to maintenance dose once stable. **Anti-inflammatory/Immunosuppressive** - **Dose**: **20-240 mg/day**. - **Frequency**: Daily or divided doses. - **Route**: Oral, IV, IM. - **Duration**: Short-term, then gradual taper. - **Special Considerations**: Dose is highly individualized based on condition severity. **Septic Shock (Refractory)** - **Dose**: **200 mg** total daily dose. - **Frequency**: **50 mg** IV every **6 hours** OR continuous infusion of **10 mg/hr**. - **Route**: IV. - **Duration**: Up to 7 days, then taper. ### Dose Adjustments - **Renal Impairment**: No specific dose adjustment needed; corticosteroids are primarily hepatically metabolized. - **Hepatic Impairment**: No specific dose adjustment needed; monitor for increased effects in severe liver disease. - **Elderly Patients**: Use lowest effective dose; increased risk of adverse effects (e.g., osteoporosis, hyperglycemia). ## Pediatric Dosing ### Neonates (0-28 days) - **Indication**: Adrenal Insufficiency - **Dose**: **0.5-0.75 mg/kg/day** (oral) or **0.35-0.5 mg/kg/day** (IV). - **Frequency**: Divided **TID**. - **Maximum**: Clinical response guided. - **Special Notes**: Often combined with fludrocortisone for mineralocorticoid activity. - **Indication**: Septic Shock - **Dose**: **1 mg/kg/dose**. - **Frequency**: Every **6 hours**. - **Maximum**: Duration limited, not fixed per dose. - **Special Notes**: For vasopressor-dependent shock. ### Infants (1-12 months) - **Indication**: Adrenal Insufficiency - **Dose**: **0.5-0.75 mg/kg/day**. - **Frequency**: Divided **TID**. - **Maximum**: Clinical response guided. - **Indication**: Anti-inflammatory/Immunosuppressive - **Dose**: **0.5-4 mg/kg/day**. - **Frequency**: Divided **Q6-12h**. - **Maximum**: **240 mg/day**. ### Children (1-12 years) - **Indication**: Adrenal Insufficiency - **Dose**: **10-12 mg/m²/day** OR **0.4-0.8 mg/kg/day**. - **Frequency**: Divided **TID**. - **Maximum**: Clinical response guided. - **Indication**: Anti-inflammatory/Immunosuppressive - **Dose**: **0.5-4 mg/kg/day**. - **Frequency**: Divided **Q6-12h**. - **Maximum**: Up to **240 mg/day**. ### Adolescents (13-18 years) - **Dose**: Generally follows **adult dosing** guidelines. - **Maximum**: Same as **adult maximum doses**. ## Safety Information ### Contraindications - **Absolute**: Systemic fungal infections (unless used for adrenal insufficiency). - **Absolute**: Live or live-attenuated vaccines during immunosuppressive doses. - **Relative**: Active untreated infections, ocular herpes simplex. ### Common Adverse Effects - **Very Common (>10%)**: Fluid retention, hyperglycemia, increased appetite, insomnia, mood changes. - **Common (1-10%)**: Hypertension, osteoporosis (long-term), dyspepsia, skin thinning, increased infection risk. - **Serious but Rare**: Adrenal suppression, Cushing's syndrome, GI perforation, cataracts, glaucoma, aseptic necrosis. ### Key Drug Interactions - **CYP3A4 Inducers (e.g., rifampin, phenytoin)**: Decrease hydrocortisone levels; may need higher hydrocortisone dose. - **CYP3A4 Inhibitors (e.g., ritonavir, ketoconazole)**: Increase hydrocortisone levels; monitor for increased corticosteroid effects. - **NSAIDs**: Increased risk of GI ulceration/bleeding; use with caution. - **Warfarin**: May alter anticoagulant effect; monitor INR. - **Diuretics (thiazide, loop)**: Enhanced potassium loss; monitor electrolytes. ## Monitoring & Follow-up - **Before Treatment**: Blood pressure, weight, electrolytes, blood glucose, bone mineral density (long-term), ocular exam (long-term). - **During Treatment**: Blood pressure, weight, electrolytes, blood glucose, signs of infection, GI bleeding, growth in children. - **Clinical Signs**: Adrenal insufficiency symptoms (fatigue, weakness), Cushingoid features (moon face, striae), infection. ## Clinical Pearls - 💡 **Tip 1**: Administer oral doses with food to minimize GI upset. - 💡 **Tip 2**: Taper dose gradually after prolonged systemic use to prevent adrenal crisis. - 💡 **Tip 3**: Patients on chronic therapy need "stress doses" during illness/surgery. - 💡 **Tip 4**: Hydrocortisone is short-acting; consider longer-acting agents for single daily dosing in non-replacement uses. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.