Hydrocortisone Premedication Before Liposomal Amphotericin B
Hydrocortisone premedication is NOT routinely recommended before liposomal amphotericin B; instead, use diphenhydramine or acetaminophen as first-line premedication, reserving glucocorticosteroids (such as hydrocortisone 25 mg IV) only for patients who develop severe infusion-related reactions despite standard premedication. 1, 2
Standard Premedication Protocol
The recommended approach for preventing infusion-related reactions with liposomal amphotericin B includes:
- Diphenhydramine or acetaminophen should be administered prior to infusion as the primary premedication strategy 1, 2
- Administer 1 L of normal saline before and after the infusion in patients who can tolerate fluids to reduce nephrotoxicity 1, 2
- This standard premedication approach is effective for most patients receiving liposomal amphotericin B 1
When to Consider Glucocorticosteroids
Glucocorticosteroids like hydrocortisone have a limited role and should only be used in specific circumstances:
- Reserve glucocorticosteroids for rare cases where severe infusion-related reactions occur despite standard premedication with diphenhydramine and acetaminophen 3
- If glucocorticosteroids are needed, administer approximately 30 minutes before the infusion 3
- The typical dose used in clinical practice is hydrocortisone 25 mg IV, based on historical protocols 4
Important Clinical Context
The evidence strongly suggests against routine glucocorticosteroid premedication:
- Liposomal amphotericin B has significantly fewer infusion-related reactions (20%) compared to conventional amphotericin B (44-54%), making aggressive premedication less necessary 5, 6
- Empirical premedication regimens (including corticosteroids) showed no superiority over no pretreatment in preventing infusion-related adverse events in a large prospective study of 397 patients 7
- The recommended strategy is to treat symptoms when they first arise, then premedicate for subsequent infusions rather than using empirical premedication for all patients 7
Monitoring During Infusion
If infusion-related reactions occur despite premedication:
- Monitor for chest pain, dyspnea, hypoxia, severe abdominal/flank/leg pain, flushing, and urticaria 1, 5
- Temporarily interrupt the infusion and administer intravenous diphenhydramine if reactions develop 1
- Consider adding hydrocortisone for subsequent infusions only if reactions were severe 3
Common Pitfalls to Avoid
- Do not routinely use hydrocortisone premedication as it adds unnecessary medication exposure without proven benefit for most patients receiving liposomal amphotericin B 7
- Do not assume cross-reactivity between different amphotericin B formulations—patients who react to one lipid formulation may tolerate another 8
- Distinguish between liposomal amphotericin B and conventional amphotericin B—the latter has much higher rates of infusion reactions and historically required more aggressive premedication strategies 9, 6