From the Guidelines
Hydroprednisolone should be used at a dose of 15-20 mg in divided doses for the treatment of adrenal insufficiency in patients with immune-related adverse events, with the goal of recreating the diurnal rhythm of cortisol. The management of adrenal insufficiency in these patients requires careful consideration of the dose and duration of corticosteroid therapy, as well as education on stress dosing and emergency injectables 1.
Key Considerations
- The dose of hydroprednisolone may need to be adjusted based on the severity of symptoms, with higher doses used for acute conditions and lower doses for maintenance therapy 1.
- The use of hydroprednisolone allows for the recreation of the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon 1.
- Patients with adrenal insufficiency require education on stress dosing, emergency injectables, and when to seek medical attention for impending adrenal crisis, as well as a medical alert bracelet or necklace for adrenal insufficiency 1.
- The lowest effective dose of hydroprednisolone should be used for the shortest necessary duration to minimize the risks of side effects, including increased risk of infection, elevated blood sugar, fluid retention, mood changes, and with prolonged use, osteoporosis and adrenal suppression 1.
Special Considerations
- In patients with severe symptoms, medically significant or life-threatening consequences, or unable to perform activities of daily living, hospitalization may be necessary to provide normal saline, IV stress dose steroids, and other supportive care 1.
- The use of prednisone or equivalent may be considered in special circumstances, but the risk of over-replacement and reduced survival on higher doses should be taken into account 1.
- Laboratory confirmation of adrenal insufficiency should not be attempted in patients given high-dose corticosteroids for other immune-related adverse events until treatment is ready to be discontinued 1.
From the Research
HYDROPREDNIS: An Overview of Corticosteroid Hypersensitivity
- Corticosteroids, such as hydrocortisone hemisuccinate, are commonly used to treat asthma and other inflammatory diseases, but they can also cause severe allergic reactions 2.
- These reactions can be immediate or delayed and can occur through various modes of administration, including injectable substances, oral, and topical routes 3, 4.
- The prevalence of corticosteroid hypersensitivity reactions is not well established, but they are considered clinically important due to the widespread use of corticosteroid medications 3.
Clinical Manifestations and Diagnosis
- Immediate hypersensitivity reactions to corticosteroids can manifest as anaphylaxis, urticaria, and/or angioedema, while delayed reactions can cause contact dermatitis 4, 5.
- Diagnosis of corticosteroid hypersensitivity reactions can be challenging, as it is often difficult to distinguish between hypersensitivity reactions and deterioration of the underlying inflammatory disease 3.
- Skin testing, patch testing, and oral graded challenge can help confirm the suspected culprit agent and identify an alternative tolerated corticosteroid 4, 5.
Management and Treatment
- Management of corticosteroid hypersensitivity reactions requires immediate and permanent withdrawal of the implicated product, as well as symptomatic treatment and, in some cases, antihistamine and adrenaline administration 2.
- Alternative corticosteroid agents can be administered, and desensitization may be required in rare cases 5.
- Physicians should be aware of the potential for corticosteroids to cause hypersensitivity reactions and maintain a high index of suspicion to identify the culprit corticosteroid 3.