Why is hydrocortisone (cortisol) used for adrenal hemorrhage?

From the Guidelines

Hydrocortisone is the primary treatment for adrenal hemorrhage because it replaces the cortisol that the damaged adrenal glands can no longer produce, as recommended by the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. When adrenal hemorrhage occurs, it often leads to adrenal insufficiency as the glands become unable to secrete adequate amounts of cortisol, which is essential for stress response, glucose metabolism, and maintaining blood pressure. The typical regimen involves stress-dose hydrocortisone (100mg IV every 8 hours initially) followed by maintenance therapy (typically 15-25mg oral hydrocortisone daily, divided into 2-3 doses with the largest dose in the morning) as suggested by the guidelines 1. This replacement therapy prevents the potentially life-threatening consequences of adrenal crisis, including hypotension, hypoglycemia, and electrolyte abnormalities. Some key points to consider in the management of adrenal hemorrhage include:

• Close monitoring of clinical symptoms and electrolytes to adjust dosing appropriately 1
• The need for lifelong replacement therapy in many patients, though some may recover adrenal function if the hemorrhage was limited and some functional tissue remains
• The potential need for fludrocortisone (0.05-0.2mg daily) if aldosterone deficiency is present, particularly if the patient shows signs of volume depletion or hyperkalemia 1 It is essential to follow the most recent guidelines and consult with an endocrinologist to ensure the best possible outcome for patients with adrenal hemorrhage. The guidelines emphasize the importance of recognizing and diagnosing adrenal crisis, which can be a medical emergency, and providing adequate glucocorticoid replacement therapy to prevent long-term adverse consequences 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Glucocorticoids, naturally occurring and synthetic, are adrenocortical steroids that are readily absorbed from the gastrointestinal tract. Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states Hydrocortisone is used for adrenal hemorrhage because it is a replacement therapy for adrenocortical deficiency states.

• The main reason is to replace the deficient hormones in the body.
• This is due to the fact that adrenal hemorrhage can lead to adrenocortical deficiency. 2

From the Research

Hydrocortisone Treatment for Adrenal Hemorrhage

• Hydrocortisone is used to treat adrenal hemorrhage due to its ability to replace the deficient glucocorticoids and mineralocorticoids produced by the adrenal cortex 3.
• Adrenal hemorrhage can lead to adrenocortical insufficiency, which may result in an adrenal crisis, a life-threatening condition that requires prompt initiation of therapy with hydrocortisone 3, 4.
• The diagnosis of adrenal hemorrhage is often delayed due to its nonspecific presentation, and physicians must be aware of the risk factors for bleeding, such as anticoagulation and thrombocytopenia, to consider the diagnosis 3, 5, 4.

Dosage and Administration of Hydrocortisone

• The initial treatment for adrenal insufficiency due to adrenal hemorrhage involves substituting hydrocortisone in a higher dosage, which can be reduced to a substitution dosage (15-25 mg/day divided into two to three doses/day) during the course of treatment 3.
• In cases of major stress, such as trauma or surgery, hydrocortisone must be administered in higher dosages (e.g., 100 mg i.v.) to prevent adrenal crisis 3, 6.
• Continuous intravenous hydrocortisone infusion is recommended over intermittent bolus administration to maintain cortisol concentrations in the required range during major stress 6.

Importance of Prompt Treatment

• Prompt diagnosis and treatment of adrenal hemorrhage are crucial to prevent adrenal crisis and potentially fatal outcomes 3, 5, 4.
• Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid adrenal crisis, and the treatment regimen should be individualized to replicate the natural circadian rhythm of cortisol release 6, 7.