Hydrocortisone Increases Blood Pressure and Should Not Be Used to Treat Hypertension
Hydrocortisone raises blood pressure through multiple mechanisms and is contraindicated for managing hypertension—it causes hypertension rather than treating it. The evidence-based first-line treatments for hypertension are ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1.
Why Hydrocortisone Raises Blood Pressure
Hydrocortisone consistently increases systolic blood pressure by approximately 5 mmHg even at physiological replacement doses 2. The mechanisms include:
- Increased cardiac output from expanded blood volume, raising systolic BP from 119 to 135 mmHg in healthy volunteers receiving 200 mg/day 3
- Enhanced vascular sensitivity to norepinephrine, with a leftward shift in the dose-response curve and increased forearm vascular resistance during cold pressor testing 3
- Suppression of the renin-angiotensin-aldosterone system, with decreased aldosterone and renin levels, plus a drop in plasma potassium 2
- Altered 11β-hydroxysteroid dehydrogenase enzyme activity, increasing the cortisol-to-cortisone ratio and potentially enhancing mineralocorticoid receptor stimulation 2, 4
In children with congenital adrenal hyperplasia, evening dosing of hydrocortisone increased 24-hour systolic BP by more than 1 standard deviation compared to morning dosing 5.
Evidence-Based Treatment for Hypertension
Initial Pharmacologic Therapy
For confirmed office BP ≥130/80 mmHg, initiate treatment with drugs proven to reduce cardiovascular events 1:
- ACE inhibitors or ARBs are first-line for patients with diabetes, chronic kidney disease (albuminuria ≥30 mg/g creatinine), or coronary artery disease 1, 6, 7
- Thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) have the strongest evidence for reducing heart failure events 1, 6
- Dihydropyridine calcium channel blockers are equally effective and preferred in Black patients 1
Combination Therapy Strategy
For BP ≥150/90 mmHg (or ≥160/100 mmHg in diabetes guidelines), immediately initiate two-drug therapy or a single-pill combination 1:
- Combine an ACE inhibitor or ARB with either a thiazide-like diuretic or dihydropyridine calcium channel blocker 6, 7
- Single-pill combinations significantly improve medication adherence 7
- Never combine ACE inhibitor + ARB, as this increases adverse events without cardiovascular benefit 1, 6
Blood Pressure Targets
Target BP <130/80 mmHg for most adults with hypertension 1:
- The 2024 ESC guidelines recommend targeting systolic BP 120-129 mmHg if well-tolerated, particularly for high cardiovascular risk patients 1
- For adults ≥85 years or those with symptomatic orthostasis or moderate-to-severe frailty, consider a target <140/90 mmHg 1
Resistant Hypertension Management
If BP remains ≥140/90 mmHg despite three drugs (including a diuretic), add spironolactone as the fourth agent 1:
- Mineralocorticoid receptor antagonists are effective for resistant hypertension when added to ACE inhibitor/ARB, thiazide-like diuretic, and dihydropyridine calcium channel blocker 1
- Monitor serum creatinine and potassium within 7-14 days and at least annually, as combining spironolactone with ACE inhibitor/ARB increases hyperkalemia risk 1, 7
Critical Pitfalls to Avoid
- Do not use hydrocortisone or other glucocorticoids to lower blood pressure—they have the opposite effect 2, 3
- Exclude secondary causes of hypertension before diagnosing resistant hypertension, including medication nonadherence, white coat hypertension, and excess glucocorticoid states 1
- Never combine ACE inhibitor + ARB + direct renin inhibitor, as this combination is potentially harmful 1, 6
- Beta-blockers are not first-line for uncomplicated hypertension unless there are compelling indications (post-MI, angina, heart failure with reduced ejection fraction) 1, 6, 7