What are the indications for hydrocortisone?

Hydrocortisone Indications

Hydrocortisone is indicated for adrenal insufficiency (primary and secondary), peri-operative stress coverage in patients with adrenal insufficiency or chronic steroid use, septic shock requiring vasopressor support, and a broad range of inflammatory and autoimmune conditions including severe allergic reactions, rheumatologic diseases, respiratory disorders, hematologic conditions, and certain malignancies. 1, 2

Primary Indications by Clinical Context

Adrenal Insufficiency (Replacement Therapy)

• Primary adrenal insufficiency (Addison's disease) – Hydrocortisone 15–25 mg daily in divided doses (typically 10–15 mg morning, 5–10 mg early afternoon) provides physiologic glucocorticoid replacement. 1
• Secondary adrenal insufficiency – Same dosing as primary disease, but fludrocortisone is not required since the renin-angiotensin-aldosterone system remains intact. 1
• Acute adrenal crisis – Hydrocortisone 100 mg IV bolus immediately, followed by continuous infusion of 200 mg over 24 hours (or 50 mg IV/IM every 6 hours), plus aggressive saline resuscitation. 1, 3
• Graded severity approach – Mild (Grade 1): 15–20 mg/day oral; Moderate (Grade 2): 30–50 mg/day oral; Severe (Grade 3–4): 50–100 mg IV every 6–8 hours. 1

Peri-operative Stress Coverage

• Major surgery in patients with adrenal insufficiency – Hydrocortisone 100 mg IV at induction, then 200 mg/24 hours continuous infusion intra-operatively and post-operatively while NPO. 4, 1
• Alternative to infusion – Hydrocortisone 50 mg IV or IM every 6 hours if continuous infusion is unavailable. 4, 1
• Post-operative oral transition – Once tolerating oral intake, give double the usual maintenance dose for 48 hours (or up to one week after major surgery), then resume standard maintenance. 4, 1
• Intermediate/minor surgery – Hydrocortisone 100 mg IV/IM at procedure start, then double oral maintenance dose for 24–48 hours. 1
• Labor and vaginal delivery – Hydrocortisone 100 mg IV at onset of labor, followed by 200 mg/24 hours continuous infusion (or 100 mg IM then 50 mg every 6 hours IM). 4, 1, 5
• Patients on chronic steroids – Those receiving prednisolone ≥5 mg (or equivalent) for ≥4 weeks require the same peri-operative coverage as patients with confirmed adrenal insufficiency. 4

Septic Shock

• Vasopressor-dependent septic shock – Initiate hydrocortisone 200 mg/24 hours continuous IV infusion only after adequate fluid resuscitation and when vasopressor support (norepinephrine ≥0.25 µg/kg/min for ≥4 hours) fails to achieve hemodynamic stability. 1
• Do not use ACTH stimulation testing – Start hydrocortisone based on clinical criteria alone; ACTH testing should not guide the decision to initiate corticosteroids in septic shock. 1
• Taper when stable – Gradually reduce hydrocortisone once vasopressors are discontinued; abrupt cessation risks rebound hypotension. 1
• Contraindication – Do not give corticosteroids to patients with sepsis who are not in shock. 1

FDA-Approved Inflammatory and Autoimmune Conditions

• Rheumatologic diseases – Polymyositis, dermatomyositis, systemic lupus erythematosus, and other connective tissue disorders during acute exacerbations. 2
• Severe allergic reactions – Stevens-Johnson syndrome, drug hypersensitivity reactions, and severe dermatologic conditions. 2
• Ophthalmic inflammation – Optic neuritis, sympathetic ophthalmia, anterior and posterior uveitis, and choroiditis. 2
• Respiratory diseases – Symptomatic sarcoidosis, Loeffler's syndrome, berylliosis, aspiration pneumonitis, and fulminating pulmonary tuberculosis (with concurrent antituberculous therapy). 2
• Hematologic disorders – Idiopathic thrombocytopenic purpura in adults, secondary thrombocytopenia, acquired hemolytic anemia, erythroblastopenia, and congenital hypoplastic anemia. 2
• Neoplastic diseases – Palliative management of leukemias and lymphomas in adults, and acute leukemia of childhood. 2
• Edematous states – Nephrotic syndrome (idiopathic or due to lupus erythematosus) to induce diuresis or remission of proteinuria. 2
• Gastrointestinal diseases – Ulcerative colitis and regional enteritis (Crohn's disease) during critical periods. 2
• Neurologic conditions – Acute exacerbations of multiple sclerosis, tuberculous meningitis with subarachnoid block (with concurrent antituberculous therapy), and trichinosis with neurologic or myocardial involvement. 2

Critical Dosing Considerations

Route-Specific Guidance

• Intravenous preferred for acute illness – IV administration ensures reliable absorption in critically ill patients with impaired gut perfusion or vomiting. 1, 3
• Intramuscular acceptable alternative – IM hydrocortisone 50 mg every 6 hours provides equivalent coverage to 200 mg/24 hours IV infusion when IV access is problematic. 4, 5
• Oral for stable patients – Conventional immediate-release hydrocortisone tablets require 2–3 divided doses daily due to the 1.5-hour elimination half-life. 6

Mineralocorticoid Activity

• High-dose hydrocortisone provides mineralocorticoid effect – Doses ≥100 mg saturate 11β-HSD type 2 enzymes, allowing hydrocortisone to bind mineralocorticoid receptors and support blood pressure. 3
• Fludrocortisone required for primary adrenal insufficiency – Once oral intake resumes after acute illness, add fludrocortisone 0.05–0.2 mg daily for patients with primary disease. 1, 3
• Dexamethasone lacks mineralocorticoid activity – Dexamethasone 6–8 mg IV provides 24-hour glucocorticoid coverage equivalent to hydrocortisone 200 mg, but it is inadequate for primary adrenal insufficiency without fludrocortisone supplementation. 1, 5

Common Pitfalls and Safety Considerations

• Never delay treatment for diagnostic confirmation – In suspected adrenal crisis, draw cortisol and ACTH levels but start hydrocortisone 100 mg IV immediately without waiting for results. 1, 3
• Avoid abrupt discontinuation – Always taper stress-dose steroids gradually over 48 hours to one week depending on clinical recovery; abrupt cessation risks precipitating adrenal crisis. 1, 3
• Monitor glucose closely – Expect a 40–60% increase in insulin requirements with stress-dose steroids; blood glucose monitoring is essential, especially in diabetic patients. 1
• Pre-treat before thyroid hormone – Begin corticosteroids several days before initiating thyroid replacement in patients with suspected hypopituitarism to prevent precipitating adrenal crisis. 1
• Patient education mandatory – All patients with adrenal insufficiency require instruction on stress-dosing, emergency injectable hydrocortisone, and wearing a medical-alert bracelet. 1
• Cardiovascular effects at higher doses – Hydrocortisone doses in the upper physiologic range (0.4–0.6 mg/kg) increase systolic blood pressure by approximately 5 mmHg and suppress the renin-angiotensin-aldosterone system. 7