Prescribing Hydrocortisone 2.5% Rectal Cream
For mild-to-moderate ulcerative proctitis or proctosigmoiditis, prescribe hydrocortisone 2.5% rectal cream 2-4 applications daily as second-line therapy when patients are intolerant of or refractory to mesalamine suppositories. 1, 2
Clinical Positioning
Rectal mesalamine remains first-line therapy for ulcerative proctitis and proctosigmoiditis, with rectal corticosteroids reserved for patients who cannot tolerate or fail mesalamine therapy 1
The AGA guidelines specifically state that rectal corticosteroid therapy should be used "rather than no therapy for induction of remission" in patients intolerant of or refractory to mesalamine suppositories 1
Patients who place higher value on avoiding difficulties with mesalamine enemas and lower value on effectiveness may reasonably select rectal corticosteroid foam preparations 1
Dosing Regimen
Apply 2-4 times daily as indicated on the FDA-approved labeling 2
The standard formulation contains 25 mg hydrocortisone per gram 2
Available in 20-gram and 30-gram tubes 2
Store at room temperature 20°C-25°C (68°-77°F) 2
Duration and Monitoring
Use for induction of remission only - corticosteroids are not recommended for long-term maintenance therapy in ulcerative colitis 3
If no adequate response within 2 weeks, escalate to oral corticosteroids or advanced therapy 3
Systemic absorption is minimal (bioavailability 3.1-4.5%), so risk of systemic side effects is very low 4
Key Clinical Considerations
Do not use for maintenance therapy - the 2025 British Society of Gastroenterology guidelines explicitly state that corticosteroids are not recommended for long-term maintenance in ulcerative colitis 3
Rectal corticosteroids are less effective than mesalamine enemas for proctosigmoiditis, but may be preferred by patients who find mesalamine enemas difficult to use 1
For external use only; not for ophthalmic use 2
Ensure the tube seal is intact before dispensing - do not use if seal has been punctured 2