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# IV Hydrocortisone for Acute Asthma
## Overview
Hydrocortisone is a short-acting systemic corticosteroid used in acute asthma exacerbations when oral administration is not feasible (e.g., severe vomiting, impending respiratory failure, or unconsciousness). It is rarely a first-line agent, as oral prednisone or prednisolone are preferred for their bioavailability and efficacy.
## Primary Indications
Treatment of acute, severe asthma exacerbations not responding to initial intensive bronchodilator therapy.
## Adult Dosing
* **Dose:** 100 mg IV every 6 to 8 hours.
* **Transition:** Transition to oral therapy (e.g., prednisone) as soon as the patient can tolerate oral medications.
## Pediatric Dosing
* **Dose:** 2 mg/kg to 4 mg/kg per dose.
* **Frequency:** Every 6 hours.
* **Maximum:** 100 mg per dose.
* **Note:** Always consult local pediatric emergency protocols; dosing may vary based on clinical guidelines (e.g., PALS/GINA).
## Dose Adjustments
* **Renal/Hepatic Impairment:** Generally not required for short-term acute therapy.
* **Chronic Corticosteroid Use:** Patients on long-term systemic steroids may require higher stress-dose adjustments; do not discontinue abruptly.
## Contraindications
* Systemic fungal infections.
* Hypersensitivity to hydrocortisone or formulation components.
* Avoid administration of live vaccines.
## Adverse Effects
* **Short-term:** Hyperglycemia, hypertension, fluid retention/edema, hypokalemia, and psychomotor agitation.
* **Gastrointestinal:** Dyspepsia or increased risk of peptic ulceration (rare with short courses).
## Key Drug Interactions
* **CYP3A4 Inducers:** (e.g., phenytoin, rifampin) may decrease hydrocortisone efficacy.
* **CYP3A4 Inhibitors:** (e.g., ketoconazole, ritonavir) may increase corticosteroid exposure and systemic effects.
* **Diuretics:** Increased risk of hypokalemia when used concurrently with loop diuretics.
## Monitoring
* **Clinical:** Respiratory rate, oxygen saturation, work of breathing, and peak flow (if patient is able).
* **Labs:** Blood glucose (especially in diabetics), serum potassium if long-term use is expected, and signs of secondary infection.
* **Vitals:** Blood pressure.
## Clinical Pearls
* **Bioavailability:** IV hydrocortisone has a fast onset of action but is often preferred only for its IV route; it is less potent than methylprednisolone.
* **Onset Speed:** Corticosteroids take 4–6 hours to show therapeutic effects in acute asthma; do not delay starting treatment while waiting for the effect.
* **Tapering:** Short-term (<7–10 days) use for acute asthma generally does not require a formal taper, but individual clinical status should dictate the plan upon discharge.
* **Protocols:** Verify institutional guidelines, as preferred systemic corticosteroid (e.g., Methylprednisolone vs. Hydrocortisone) varies by hospital.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical guidelines and local protocols vary significantly. Always verify doses against current patient weight, institutional formulary, local pediatric emergency guidelines, and the official manufacturer prescribing information before administration.
