Can a patient use hydrocortisone (corticosteroid)?

Can a Patient Use Hydrocortisone?

Yes, patients can and should use hydrocortisone when clinically indicated for specific conditions including adrenal insufficiency, acute severe ulcerative colitis, COPD exacerbations, septic shock (when hemodynamically unstable), immune-related adverse events from checkpoint inhibitors, and various other inflammatory conditions. 1

Primary Indications for Hydrocortisone

Adrenal Insufficiency (Replacement Therapy)

• Hydrocortisone 15-20 mg daily in divided doses is the preferred corticosteroid for replacement therapy in patients with primary or secondary adrenal insufficiency 2
• The typical dosing regimen is 10 mg in the morning and 5-10 mg in the early afternoon to mimic the physiological diurnal cortisol rhythm 3
• Patients require education on stress dosing (doubling or tripling the dose during illness), emergency injectable hydrocortisone availability, and must wear a medical alert bracelet 2, 3
• All patients need corticosteroid replacement started first before other hormone replacements to avoid precipitating adrenal crisis 2

Acute Severe Ulcerative Colitis

• Intravenous hydrocortisone 100 mg every 6 hours is recommended as first-line treatment for hospitalized patients with acute severe ulcerative colitis 2
• Alternative dosing is methylprednisolone 30 mg every 12 hours, which is equally effective 2
• Treatment should continue for a defined period of 7-10 days maximum, as extending therapy beyond this carries no additional benefit 2
• If no response after 3 days, rescue therapy with infliximab or ciclosporin should be initiated rather than continuing ineffective corticosteroids 2

COPD Exacerbations

• A 7-14 day course of prednisolone 30 mg/day or hydrocortisone 100 mg (if oral route not possible) is common practice for moderate to severe exacerbations 2
• Corticosteroids should be discontinued after the acute episode unless proven effective when the patient is clinically stable 2

Septic Shock

• Hydrocortisone 200 mg per day is suggested only when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability 2
• The recommendation is against using hydrocortisone if hemodynamic stability can be achieved with fluids and vasopressors alone 2
• When used, hydrocortisone should be given as continuous infusion and tapered when vasopressors are no longer required 2
• Corticosteroids should not be administered for sepsis in the absence of shock 2

Immune Checkpoint Inhibitor-Related Adverse Events

• For severe hypophysitis or adrenal insufficiency (Grade 3-4), IV stress-dose hydrocortisone 50-100 mg every 6-8 hours is indicated 2
• Stress doses should be tapered down to oral maintenance doses over 5-7 days 2
• For moderate symptoms (Grade 2), outpatient corticosteroid treatment at 2-3 times maintenance dose (hydrocortisone 30-50 mg total) can be initiated 2

Dosing Principles and Monitoring

General Dosing Guidelines

• Initial dosage may vary from 20 mg to 240 mg per day depending on the disease entity being treated 1
• Dosage requirements are highly variable and must be individualized based on the disease and patient response 1
• After favorable response, decrease the initial dose in small decrements at appropriate intervals until the lowest effective dose is reached 1
• If long-term therapy is to be stopped, withdraw gradually rather than abruptly 1

Important Pharmacokinetic Considerations

• Hydrocortisone has a short elimination half-life of approximately 1.5 hours, requiring multiple daily doses 4, 5
• Hydrocortisone must be held for 24 hours before assessing endogenous cortisol function, as therapeutic steroids interfere with cortisol assays 2, 6
• The measurement of therapeutic steroids in cortisol assays varies, making AM cortisol unreliable in patients currently on corticosteroids 2

Critical Safety Considerations

When Hydrocortisone Should NOT Be Used or Used With Caution

• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Evidence for benefit is unclear and inconsistent, with some studies showing no mortality benefit on multivariate analysis 2
• Chronic uninterrupted topical application of 1% hydrocortisone can cause rosacea-like eruptions, perioral dermatitis, atrophy, and telangiectasia, particularly on vulnerable areas like eyelids 7
• Patients with known adrenal insufficiency should never discontinue hydrocortisone for testing without medical supervision due to risk of adrenal crisis 6

Stress Dosing Requirements

• Physical stress from procedures, illness, or surgery increases cortisol requirements, necessitating increased hydrocortisone doses 8
• Endocrine consultation is recommended prior to any procedure for stress-dose planning 8
• Patients should take regular doses on the day before and morning of procedures, with consideration for an extra morning dose 1 hour prior 8

Common Clinical Pitfalls to Avoid

• Do not use intramuscular cortisone acetate for acute adrenal insufficiency or stress situations, as it is ineffective in elevating plasma cortisol levels; use hydrocortisone instead 9
• Do not delay surgery in acute severe ulcerative colitis beyond 7 days of failed rescue therapy, as delay increases surgical complications 2
• Do not use the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone 2
• Do not start other hormone replacements before corticosteroids in patients with multiple endocrine deficiencies, as other hormones accelerate cortisol clearance and can precipitate adrenal crisis 2
• ACTH stimulation testing can give false-negative results early in hypophysitis, as adrenal reserve declines slowly after pituitary stimulation is lost 2