Injection Site for Solucortef in Addisonian Crisis
Administer hydrocortisone 100 mg intravenously as the immediate first-line route in Addisonian crisis, with intramuscular injection serving as an acceptable alternative when IV access is unavailable. 1, 2
Primary Route: Intravenous Administration
The intravenous route is strongly preferred for initial emergency management because it provides the most rapid onset of action when minutes matter in a life-threatening crisis. 1, 2, 3
- Administer as an IV bolus over 30 seconds to 10 minutes depending on the dose (100 mg can be given over 30 seconds). 3
- IV administration ensures immediate systemic availability and saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect at this high dose. 2
- The European Society of Endocrinology emphasizes that treatment must never be delayed for diagnostic procedures—if clinical suspicion exists, give intravenous hydrocortisone 100 mg immediately. 2
Alternative Route: Intramuscular Injection
Intramuscular administration is the acceptable backup when IV access cannot be rapidly established. 4, 5, 2
- The FDA label explicitly states that IM injection is an acceptable method for initial emergency use, though IV injection is preferred. 3
- For IM administration, prepare the solution by adding not more than 2 mL of Bacteriostatic Water for Injection to the 100 mg vial. 3
- Avoid the deltoid muscle due to high incidence of subcutaneous atrophy—choose larger muscle groups like the gluteus or vastus lateralis instead. 3
- Obstetric guidelines specifically mention hydrocortisone 50 mg IM every 6 hours as an alternative to continuous IV infusion during labor. 4, 5
Routes to Avoid
Never use subcutaneous, epidural, intra-articular, or intratendinous routes for Addisonian crisis. 3
- The FDA explicitly warns against epidural administration of corticosteroids due to serious neurologic events including spinal cord infarction, paraplegia, and stroke. 3
- Subcutaneous injection may result in dermal and subdermal changes forming depressions at the injection site. 3
Subsequent Dosing After Initial Bolus
Following the initial 100 mg bolus, continue with either:
- Continuous IV infusion of hydrocortisone 200 mg over 24 hours, OR 4, 1, 2
- Hydrocortisone 50 mg IV or IM every 6 hours until the patient stabilizes and can tolerate oral medications. 1, 2
Critical Clinical Pitfall
The most dangerous error is delaying treatment while attempting to establish IV access or obtain diagnostic confirmation. 1, 2 If IV access is difficult, immediately give the 100 mg dose intramuscularly rather than waste precious minutes—the IM route provides adequate absorption in this emergency setting, and mortality increases with delayed intervention. 2, 6