Is Hydrocortisone Safe and Can It Be Given Orally?
Hydrocortisone is safe when used appropriately and is routinely administered in oral pill form for replacement therapy in adrenal insufficiency, with typical maintenance doses of 15-25 mg daily divided into 2-3 doses. 1, 2
Safety Profile
Hydrocortisone is structurally identical to cortisol, the body's natural stress hormone, making it the preferred glucocorticoid for replacement therapy. 1 The medication has excellent oral bioavailability and is rapidly absorbed from the gastrointestinal tract. 3, 4
Short-term use carries minimal risk, with no long-term adverse consequences when given for acute stress situations like surgery or illness. 1 This is a critical point—clinicians should not hesitate to administer hydrocortisone when indicated, as the risks of under-treatment far exceed those of brief supplementation.
Potential Risks to Monitor
Long-term or excessive dosing can cause:
- Iatrogenic Cushing's syndrome: bruising, thin skin, edema, weight gain, hypertension, hyperglycemia 2, 5
- Metabolic effects: elevated blood pressure, salt and water retention, increased potassium excretion 3
- Bone health: increased calcium excretion, requiring bone density monitoring every 3-5 years 1
- Ocular complications: posterior subcapsular cataracts and glaucoma with prolonged use 3
- Infection susceptibility: corticosteroids may mask infection signs and reduce immune response 3
The key is using the lowest dose compatible with health and well-being. 1
Oral Administration
Standard Oral Dosing
Hydrocortisone tablets are available in 5 mg, 10 mg, and 20 mg strengths. 3 For maintenance therapy in adrenal insufficiency:
- Adults: 15-25 mg daily (or 18.75-31.25 mg cortisone acetate equivalent) 1, 2
- Dosing schedule: Split into 2-3 doses, with the first dose immediately upon waking and the last dose at least 6 hours before bedtime 1
- Typical pattern: Two-thirds of the daily dose in the morning, one-third in the afternoon 2
- Children: 6-10 mg/m² body surface area 1
This dosing strategy attempts to mimic the natural diurnal cortisol rhythm, though the short 90-minute half-life of oral hydrocortisone makes perfect replication impossible. 1, 6
Stress Dosing
During illness or physiological stress, patients must double or triple their oral doses to prevent adrenal crisis. 2, 5 After uncomplicated surgery, double the regular oral dose for 48 hours, extending up to one week for major procedures. 1, 7
Transition from IV to Oral
When converting from intravenous to oral hydrocortisone, use a 1:1 dose equivalence. 7 Ensure the patient can tolerate oral intake before discontinuing IV therapy—if prolonged nil-by-mouth status is anticipated, continue IV dosing. 7
Critical Safety Considerations
Absolute Requirements for All Patients
- Medical alert identification: All patients must wear medical alert jewelry and carry a steroid card 1, 2
- Emergency supplies: Provide injectable hydrocortisone with instructions for self-administration 1, 2
- Patient education: Comprehensive teaching on stress dosing and recognition of adrenal crisis is mandatory 2, 5
Special Populations
Pregnancy: The benefits must be weighed against potential risks. Infants born to mothers on substantial doses should be observed for hypoadrenalism. 3 During labor, IV hydrocortisone 100 mg is given at onset, followed by continuous infusion. 1, 5
Primary vs. Secondary Adrenal Insufficiency: Patients with primary adrenal insufficiency (Addison's disease) typically require fludrocortisone 50-200 mcg daily in addition to hydrocortisone for mineralocorticoid replacement. 1, 2 This is not needed in secondary adrenal insufficiency.
Drug interactions: Patients taking CYP3A4 inducers may require higher doses due to increased hydrocortisone metabolism. 1 Maintain high suspicion for adrenal crisis in these patients.
Contraindications and Precautions
- Avoid live vaccines during corticosteroid therapy, especially at high doses, due to neurological complication risks and poor antibody response 3
- Active tuberculosis: Restrict use to fulminating or disseminated cases with concurrent antituberculous therapy 3
- Chickenpox/measles exposure: Nonimmune patients on corticosteroids face serious or fatal complications; consider prophylaxis with VZIG or IG if exposed 3
Common Pitfalls
Never delay treatment for diagnostic procedures in suspected adrenal crisis—draw blood for cortisol and ACTH, then immediately start hydrocortisone 100 mg IV 1, 7
Always start glucocorticoids before thyroid replacement when both are needed, to prevent precipitating adrenal crisis 2
Do not use dexamethasone alone in primary adrenal insufficiency—it lacks mineralocorticoid activity 1, 7
Avoid abrupt discontinuation in patients on chronic therapy, as this can precipitate adrenal crisis
Monitor for under-replacement: fatigue, nausea, hypotension, electrolyte abnormalities indicate inadequate dosing 5