What is the role of hydrocortisone (corticosteroid) after streptokinase (fibrinolytic agent) administration?

Hydrocortisone After Streptokinase Administration

Routine administration of hydrocortisone after streptokinase is not indicated according to current guidelines. 1

Rationale for Not Using Prophylactic Hydrocortisone

The 2008 European Society of Cardiology (ESC) guidelines for management of ST-segment elevation myocardial infarction explicitly state that "routine administration of hydrocortisone is not indicated" following streptokinase administration 1. This recommendation has been maintained in subsequent ESC guidelines.

Streptokinase-related adverse effects include:

• Hypotension (common)
• Allergic reactions (rare)
• Anaphylaxis (very rare)

Management of Streptokinase-Induced Hypotension

When hypotension occurs during streptokinase administration, the recommended approach is:

1. Temporarily halt the infusion
2. Lay the patient flat and elevate the feet
3. Consider atropine if bradycardia is present
4. Administer intravascular volume expansion if needed 1

Hydrocortisone is not part of this management algorithm.

Special Considerations

Allergic Reactions

While allergic reactions to streptokinase are rare, they can occur due to its antigenic properties. However:

• The evidence does not support routine pretreatment with corticosteroids 2
• Streptokinase skin testing may be more useful for identifying patients at risk for allergic reactions 3

Re-administration of Streptokinase

Streptokinase should never be readministered after 4 days from initial use due to:

• Development of antibodies from 4 days post-administration
• Antibodies can persist for at least 4 years in up to 50% of patients
• Risk of allergic reactions or neutralization of the drug 4, 5

If thrombolysis is needed after previous streptokinase exposure, a non-antigenic alternative like alteplase should be used.

Clinical Implications

1. For first-time streptokinase administration:

   • No prophylactic hydrocortisone is needed
   • Monitor for hypotension and manage as outlined above

2. For hypersensitivity reactions:

   • Treat according to standard anaphylaxis protocols
   • Epinephrine is the agent of choice for anaphylaxis-associated hypotension 2

3. For re-exposure considerations:

   • Avoid streptokinase re-administration after 4 days from initial dose
   • Consider alternative thrombolytic agents if needed

Conclusion

The evidence clearly shows that prophylactic hydrocortisone administration after streptokinase is unnecessary in routine clinical practice. Management should focus on monitoring for and appropriately treating any hypotension or allergic reactions that may occur.