Can Hydrocortisone (hydrocortisone) Solu-Cortef be administered intramuscularly (IM) or subcutaneously (SC) for emergency treatment of adrenal crisis, and which route is recommended?

Hydrocortisone Administration Routes for Adrenal Crisis

For emergency treatment of adrenal crisis, hydrocortisone 100 mg should be administered intravenously as the first-line route, with intramuscular injection as an acceptable alternative when IV access is not immediately available; subcutaneous administration is not recommended for acute adrenal crisis. 1

Approved Administration Routes

Intravenous (Preferred for Emergency)

• The FDA label for Solu-Cortef explicitly states it may be administered by intravenous injection, intravenous infusion, or intramuscular injection, with intravenous injection being the preferred method for initial emergency use 1
• IV administration allows for rapid delivery over 30 seconds to 10 minutes depending on dose, ensuring immediate systemic availability 1
• For acute adrenal crisis, administer hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of 200 mg over 24 hours 2, 3

Intramuscular (Alternative When IV Unavailable)

• IM administration is FDA-approved and explicitly listed as an acceptable route for Solu-Cortef 1
• Guidelines consistently recommend hydrocortisone 100 mg IM as an alternative when IV access cannot be established quickly 2, 4, 3
• The 2020 UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology list "hydrocortisone 50 mg every 6 hours by i.m. injection" as an alternative to continuous IV infusion for postoperative management 5
• All patients with adrenal insufficiency should be prescribed injectable hydrocortisone (100 mg IM) for emergency self-administration to prevent or treat adrenal crisis 3

Subcutaneous (Not Recommended)

• Subcutaneous administration is not mentioned in the FDA label for Solu-Cortef and is not recommended in any major guidelines for emergency treatment of adrenal crisis 1
• A 2019 study comparing subcutaneous hydrocortisone to IM administration found that the ACTH-suppressive effect was more pronounced after parenteral (IM) hydrocortisone, suggesting IM is superior 6
• The absence of SC route in all emergency protocols reflects concerns about inadequate absorption during hypotensive crisis states

Emergency Treatment Algorithm

Immediate Actions (Do Not Delay)

• Administer hydrocortisone 100 mg IV bolus over 30 seconds to 10 minutes—do not delay treatment for diagnostic testing 2, 1
• If IV access is not immediately available, give hydrocortisone 100 mg IM without delay 2, 4
• Draw blood for cortisol and ACTH levels before treatment, but never wait for results 2
• Simultaneously begin aggressive fluid resuscitation with 0.9% normal saline—infuse 1 liter over the first hour 2

Continuous Maintenance Phase

• After the initial bolus, immediately initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours (approximately 8.3 mg/hour) 5, 2
• Alternative regimen: hydrocortisone 50 mg IV or IM every 6 hours if continuous infusion is not feasible 5, 2
• Continue this dosing for 24-48 hours or until the patient is stable and able to tolerate oral intake 2

Critical Pitfalls to Avoid

Route Selection Errors

• Never use subcutaneous administration for acute adrenal crisis—absorption is unreliable and not validated in emergency settings 6
• Do not substitute dexamethasone as the primary agent—it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult 2
• The initial 100 mg bolus of hydrocortisone is critical because it saturates 11β-HSD type 2 enzymes to provide mineralocorticoid effect, which dexamethasone cannot provide 2

Timing and Dosing Errors

• Never delay hydrocortisone administration to establish IV access if it takes more than 1-2 minutes—give IM immediately instead 2, 4
• Do not use lower doses in the acute phase—100 mg is required to achieve both glucocorticoid and mineralocorticoid effects 2
• Do not abruptly stop stress-dose steroids—always taper gradually over 48 hours to one week depending on clinical recovery 2

Patient Education and Preparedness

• All patients with adrenal insufficiency must be prescribed an emergency injectable hydrocortisone kit (100 mg IM) for home use 4, 3, 7
• Patients and family members should be trained on IM self-injection technique for impending crisis 8, 7
• Every patient should carry a steroid dependency alert card and wear a medical alert bracelet 4, 7
• Educate patients to recognize adrenal crisis symptoms: severe weakness, confusion, abdominal pain, vomiting, hypotension 4