Does hydrocortisone (cortisol) cause hypokalemia?

From the Guidelines

Yes, hydrocortisone can cause low potassium (hypokalemia). According to the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage, high-dose hydrocortisone has been associated with hypokalemia, among other medical complications such as hyperglycemia, gastrointestinal hemorrhage, and congestive heart failure 1. This is likely due to the mineralocorticoid effect of hydrocortisone, which promotes potassium excretion through the kidneys. Key points to consider include:

• Hydrocortisone can increase potassium loss in the urine by binding to mineralocorticoid receptors in the kidneys
• Patients on long-term hydrocortisone therapy or those taking higher doses should monitor their potassium levels regularly
• Symptoms of low potassium may include muscle weakness, fatigue, cramping, irregular heartbeat, and in severe cases, paralysis
• Eating potassium-rich foods like bananas, oranges, potatoes, and leafy greens may help maintain normal potassium levels, but potassium supplements should only be taken under medical supervision to avoid hyperkalemia. The use of hydrocortisone should be carefully weighed against its potential risks, including hypokalemia, and alternative treatments such as fludrocortisone may be considered in certain cases 1.

From the FDA Drug Label

Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium Dietary salt restriction and potassium supplementation may be necessary.

Hydrocortisone can cause low potassium due to increased excretion of potassium, especially with average and large doses. Potassium supplementation may be necessary to prevent this effect 2.

• Key effects: increased excretion of potassium, salt and water retention
• Preventive measures: dietary salt restriction, potassium supplementation

From the Research

Hydrocortisone and Low Potassium

• Hydrocortisone can cause low potassium (hypokalemia) in some individuals, particularly when used in high doses 3, 4.
• A study published in 2004 reported a case of life-threatening hypokalemia in an asthmatic patient treated with high-dose hydrocortisone, highlighting the potential risks of mineralocorticoid side-effects 3.
• Another study published in 2023 described a patient who developed severe hypokalemia and hypertension after ingesting topical hydrocortisone cream, demonstrating the potential for systemic toxicity from topical corticosteroid use 4.
• The mechanism of hydrocortisone-induced hypokalemia is thought to be related to its mineralocorticoid properties, which can lead to renal potassium wasting and metabolic alkalosis 3, 4.

Risk Factors and Management

• Patients taking high-dose hydrocortisone or those with a history of hypertension, asthma, or other conditions may be at increased risk of developing hypokalemia 3, 4.
• Management of hypokalemia typically involves potassium replacement, either orally or intravenously, and monitoring of electrolyte levels and cardiac function 5.
• It is essential to monitor plasma acid-base and electrolyte concentrations frequently in patients treated with high-dose hydrocortisone to prevent life-threatening complications 3.

Related Complications

• Corticosteroids, including hydrocortisone, have been associated with various complications, such as avascular necrosis, gastrointestinal bleeding, and psychiatric syndromes, particularly with prolonged or high-dose use 6.
• The risk of these complications increases with higher daily and cumulative doses of corticosteroids, highlighting the need for careful consideration and monitoring in clinical practice 6.