hydrocortisone (systemic)
Cortef, Hycort ◆

hydrocortisone acetate
Cortifoam

hydrocortisone cypionate
Cortef

hydrocortisone sodium phosphate
Hydrocortone Phosphate

hydrocortisone sodium succinate
A-hydroCort, Solu-Cortef

Available forms
Available by prescription only
hydrocortisone
Enema: 100 mg/60 ml
Tablets: 5 mg, 10 mg, 20 mg
hydrocortisone acetate
Enema: 10% aerosol foam (provides 90 mg/application)
Injection: 25 mg/ml, 50 mg/ml suspension
hydrocortisone cypionate
Oral suspension: 10 mg/5 ml
hydrocortisone sodium phosphate
Injection: 50 mg/ml solution
hydrocortisone sodium succinate
Injection: 100 mg/vial, 250 mg/vial, 500 mg/vial, 1,000 mg/vial

Indications and dosages
 Severe inflammation, adrenal insufficiency.
hydrocortisone
Adults: 5 to 30 mg P.O. b.i.d., t.i.d., or q.i.d. (as much as 80 mg P.O. q.i.d. may be given in acute situations).
Children: 2 to 8 mg/kg or 16 to 240 mg/m² P.O. daily in three or four divided doses.
hydrocortisone acetate
Adults: 10 to 75 mg into joints or soft tissue at 2- or 3-week intervals. Dose varies with size of joint. In many cases, local anesthetics are injected with dose.
hydrocortisone sodium phosphate
Adults: 15 to 240 mg S.C., I.M., or I.V. daily in divided doses q 12 hours.
hydrocortisone sodium succinate
Adults: Initially, 100 to 500 mg I.M. or I.V., then 50 to 100 mg I.M. as indicated.
 Shock (other than adrenal crisis).
hydrocortisone sodium phosphate
Children: 0.16 to 1 mg/kg or 6 to 30 mg/m² I.M. daily or b.i.d.
hydrocortisone sodium succinate
Adults: 100 to 500 mg I.M. or I.V. q 2 to 6 hours.
Children: 0.16 to 1 mg/kg or 6 to 30 mg/m² I.M. or I.V. daily to b.i.d.
 Life-threatening shock.
hydrocortisone sodium succinate. Adults: 0.5 to 2 g I.V. initially, repeated at 2- to 6-hour intervals, p.r.n. High-dose therapy should be continued only until patient’s condition has stabilized. Therapy shouldn’t continue beyond 72 hours.
 Adjunctive treatment of ulcerative colitis and proctitis.
hydrocortisone. Adults: One enema (100 mg) nightly for 21 days.
hydrocortisone acetate (rectal form). Adults: 90 mg (1 applicatorful) once or twice daily for 2 or 3 weeks; decrease frequency to every other day thereafter.

Pharmacodynamics
Adrenocorticoid replacement action: Hydrocortisone is an adrenocorticoid with both glucocorticoid and mineralocorticoid properties. It’s a weak anti-inflammatory but a potent mineralocorticoid, having potency similar to that of cortisone and twice that of prednisone. Hydrocortisone (or cortisone) is usually the drug of choice for replacement therapy in patients with adrenal insufficiency. It’s usually not used for immunosuppressive activity because of the extremely large doses needed and unwanted mineralocorticoid effects.
 Hydrocortisone and hydrocortisone cypionate may be given orally. Hydrocortisone sodium phosphate may be given by I.M., S.C., or I.V. injection or by I.V. infusion, usually at 12-hour intervals. Hydrocortisone sodium succinate may be given by I.M. or I.V. injection or I.V. infusion every 2 to 10 hours, depending on the clinical situation. Hydrocortisone acetate is a suspension that may be given by intra-articular, intrasynovial, intrabursal, intralesional, or soft-tissue injection. It has a slow onset but a long duration of action. Injectable forms are usually used only when the oral dosage forms can’t be used.

Pharmacokinetics
Absorption: Absorbed readily after oral administration. After oral and I.V. administration, effects peak in about 1 to 2 hours. The acetate suspension for injection has a variable absorption over 24 to 48 hours, depending on whether it’s injected into an intra-articular space or a muscle and the blood supply to that muscle.
Distribution: Removed rapidly from the blood and distributed to muscle, liver, skin, intestines, and kidneys. Hydrocortisone is bound extensively to plasma proteins (transcortin and albumin). Only the unbound portion is active. Adrenocorticoids are distributed into breast milk and through the placenta.
Metabolism: Metabolized in the liver to inactive glucuronide and sulfate metabolites.
Excretion: Inactive metabolites and small amounts of unmetabolized drug are excreted by the kidneys. Insignificant quantities of drug are excreted in feces. Biological half-life of hydrocortisone is 8 to 12 hours.

Contraindications and precautions
Contraindicated in patients allergic to any component of the formulation, in those with systemic fungal infections, and in premature infants (with hydrocortisone sodium succinate).
  Use hydrocortisone sodium phosphate or succinate cautiously in patients with a recent MI, GI ulcer, renal disease, hypertension, osteoporosis, diabetes mellitus, hypothyroidism, cirrhosis, diverticulitis, ulcerative colitis, recent intestinal anastomosis, thromboembolic disorders, seizures, myasthenia gravis, heart failure, tuberculosis, ocular herpes simplex, emotional instability, and psychotic tendencies.

Interactions
Drug-drug. Amphotericin B, diuretics: May result in hypokalemia. Monitor serum potassium levels.
Antacids, cholestyramine, colestipol: Decreases corticosteroid effect from absorption by these drugs. May require dosage adjustment.
Barbiturates, phenytoin, rifampin: May decrease corticosteroid effects because of increased hepatic metabolism. Corticosteroid dosage may need to be increased.
Cardiac glycosides: Increases risk of toxicity. Monitor patient closely.
Estrogens: Reduces clearance of corticosteroids. Monitor patient for drug effect.
Isoniazid, salicylates: Increases metabolism of these drugs. Monitor patient carefully.
Oral anticoagulants: Decreases anticoagulant effects. Monitor PT and INR.
Ulcerogenic drugs (such as NSAIDs): Increases risk of GI ulceration. Avoid use together.

Adverse reactions
CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo, headache, paresthesia,
seizures.
CV: heart failure, hypertension, edema, arrhythmias, thrombophlebitis, thromboembolism.
EENT: cataracts, glaucoma.
GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting.
GU: menstrual irregularities.
Metabolic: hypokalemia, hyperglycemia, altered thyroid function test results.
Musculoskeletal: muscle weakness, osteoporosis, growth suppression in children.
Skin: delayed wound healing, acne, various skin eruptions, easy bruising, hirsutism.
Other: susceptibility to infections, cushingoid state (moonface, buffalo hump, central obesity), carbohydrate intolerance, acute adrenal insufficiency with increased stress (infection, surgery, trauma) or abrupt withdrawal (after long-term therapy).

Effects on lab test results
• May increase glucose and cholesterol levels. May decrease potassium and calcium levels.

Overdose and treatment
Acute ingestion, even in massive doses, is rarely a clinical problem. Toxic signs and symptoms rarely occur if drug is used for less than 3 weeks, even at large doses. However, long-term use causes adverse physiologic effects, including suppression of the hypothalamic-pituitary-adrenal axis, cushingoid appearance, muscle weakness, and osteoporosis.

Special considerations
• Determine whether patient is sensitive to other corticosteroids.
• Most adverse reactions to corticosteroids are dose- or duration-dependent.
• For better results and less toxicity, give a once-daily dose in morning.
• Give oral dose with food when possible. Patient may need medication to prevent GI irritation.
• Salt formulations aren’t interchangeable.
• Give I.M. injection deeply into gluteal muscle. Rotate injection sites to prevent muscle atrophy. Avoid S.C. injection because atrophy and sterile abscesses may occur.
• Injectable forms aren’t used for alternate-day therapy.
• Always adjust to lowest effective dose.
• Drug may mask or worsen infections, including latent amebiasis.
• Stress (fever, trauma, surgery, and emotional problems) may increase adrenal insufficiency and call for an increase in dosage.
• Watch for depression or psychotic episodes, especially during high-dose therapy.
• Periodic measurement of growth and development may be needed during high-dose or prolonged therapy in children.
• Gradually reduce dosage after long-term therapy. After abrupt withdrawal, patient may experience rebound inflammation, fatigue, weakness, arthralgia, fever, dizziness, lethargy, depression, fainting, orthostatic hypotension, dyspnea, anorexia, and hypoglycemia. After prolonged use, sudden withdrawal may be fatal.
 ALERT Don’t confuse Solu-Cortef with Solu-Medrol (methylprednisolone sodium succinate).
• Hydrocortisone suppresses reactions to skin tests, and causes false-negative results in nitroblue tetrazolium tests for systemic bacterial infections.
• Diabetic patient may need increased insulin; monitor blood glucose levels.
• Monitor patient for cushingoid effects, including moonface, buffalo hump, central obesity, thinning hair, hypertension, and increased susceptibility to infection.
Pediatric patients
• Long-term use of hydrocortisone in children and adolescents may delay growth and maturation.
Geriatric patients
• Elderly patients may be more susceptible to osteoporosis with prolonged use.

Patient education
• Caution patient to take medication as directed.
• Inform patient of potential adverse effects, and instruct him to immediately report serious adverse effects.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use