Should a patient with a history of hip pain or osteoarthritis, who has received or is scheduled to receive bilateral hip steroid injections, be placed on hydrocortisone (cortisol replacement therapy) to prevent secondary adrenal insufficiency?

Hydrocortisone (Cortisol Replacement) is NOT Indicated for Hip Steroid Injections

Patients receiving intra-articular corticosteroid injections for hip osteoarthritis do not require hydrocortisone (cortisol replacement therapy) to prevent secondary adrenal insufficiency. This is a fundamentally different clinical scenario from systemic corticosteroid therapy.

Why Hydrocortisone is Not Needed

Local vs. Systemic Corticosteroid Exposure

• Intra-articular corticosteroid injections deliver medication directly into the joint space, resulting in minimal systemic absorption compared to oral or IV corticosteroids 1
• The 2019 ACR/Arthritis Foundation guidelines strongly recommend intra-articular glucocorticoid injections for hip OA without any mention of adrenal suppression risk or need for supplemental hydrocortisone 1
• Bilateral hip injections, even when performed simultaneously, do not produce the sustained systemic corticosteroid exposure required to suppress the hypothalamic-pituitary-adrenal (HPA) axis 1

HPA Axis Suppression Requires Prolonged Systemic Exposure

• Secondary adrenal insufficiency develops from prolonged systemic corticosteroid use—typically ≥20 mg/day prednisone equivalent for ≥3 weeks 2
• The Endocrine Society confirms that iatrogenic secondary adrenal insufficiency occurs through sustained suppression of the HPA axis by therapeutic glucocorticoid use, not from local injections 2
• Even intramuscular glucocorticoid injections (40 mg triamcinolone) for hip OA, which have greater systemic absorption than intra-articular injections, are used therapeutically without hydrocortisone supplementation 3

Clinical Evidence Supporting Safety

Efficacy Without Adrenal Concerns

• Randomized controlled trials demonstrate that intra-articular corticosteroid injections provide pain relief and functional improvement in hip OA for up to 12 weeks, with no reported adrenal insufficiency complications 4
• A 2004 prospective study of 80 patients receiving 80 mg triamcinolone acetonide intra-articular hip injections showed significant pain reduction and improved function at 3 and 12 weeks without any adrenal-related adverse events 5
• A 2018 trial of intramuscular glucocorticoid injection (40 mg triamcinolone) showed sustained efficacy through 12 weeks without requiring hydrocortisone supplementation 3

Documented Risks Are Joint-Related, Not Adrenal

• The primary concerns with repeated corticosteroid injections are accelerated OA progression, subchondral insufficiency fracture, osteonecrosis complications, and rapid joint destruction—not adrenal suppression 6
• A 2024 study found that hip corticosteroid injections provided only 6.7 weeks mean relief and did not meaningfully delay time to total hip arthroplasty, but again, no adrenal complications were reported 7

When Hydrocortisone IS Actually Indicated

Confirmed Adrenal Insufficiency Only

• Hydrocortisone replacement (15-25 mg daily in divided doses) is indicated only for patients with confirmed primary or secondary adrenal insufficiency diagnosed by morning cortisol <250 nmol/L with elevated ACTH (primary) or low ACTH (secondary), or peak cortisol <500 nmol/L on cosyntropin stimulation testing 2
• Patients with established adrenal insufficiency from other causes (autoimmune Addison's disease, pituitary disorders, prolonged systemic steroid use) require lifelong replacement therapy regardless of whether they receive joint injections 2, 8

Critical Pitfall to Avoid

• Never confuse local intra-articular corticosteroid injections with systemic corticosteroid therapy—they have completely different pharmacokinetic profiles and risk profiles 1, 2
• Do not order cosyntropin stimulation testing or initiate hydrocortisone replacement based solely on a patient receiving hip injections, as this represents inappropriate testing and treatment 2

Practical Clinical Approach

• Proceed with bilateral hip corticosteroid injections as clinically indicated for osteoarthritis pain management without hydrocortisone supplementation 1
• Reserve hydrocortisone replacement therapy for patients with documented adrenal insufficiency from other causes (prolonged oral/IV corticosteroids, autoimmune disease, pituitary pathology) 2
• If a patient has been on systemic corticosteroids (≥20 mg prednisone daily for ≥3 weeks) and you're concerned about adrenal suppression, address that separately—but the hip injections themselves are not the cause 2