• Adrenocortical insufficiency; chronic use in other situations is limited because of mineralocorticoid activity.
• Used systemically and locally in a wide variety of disorders, including:
  • Inflammatory,
  • Allergic,
  • Hematologic,
  • Neoplastic,
  • Autoimmune disorders,
  • Septic shock.

Contraindicated in:

• Active untreated infections (may be used in patients being treated for tuberculous meningitis or septic shock)
• Epidural use (may result in serious neurological injury or death)
• Known alcohol, bisulfite, or tartrazine hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients).

Use Cautiously in:

• Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time)
• Hypothyroidism
• Cirrhosis
• Ulcerative colitis
• Stress (surgery, infections — supplemental doses may be needed)
• Potential infections may mask signs (fever, inflammation)
• Tumors that have a high proliferative rate, high tumor burden, and high sensitivity to cytotoxic agents (↑ risk for tumor lysis syndrome)
• Pedi: Chronic use will result in ↓ growth; use lowest possible dose for shortest period of time.

Adverse reactions/side effects are much more common with high-dose/long-term therapy

CV: hypertension.

Derm: acne, ↓wound healing, ecchymoses, fragility, hirsutism, petechiae.

EENT: cataracts, glaucoma, ↑ intraocular pressure.

Endo: adrenal suppression, cushingoid appearance (moon face, buffalo hump), hyperglycemia, PHEOCHROMOCYTOMA.

F and E: fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis.

GI: anorexia, nausea, PEPTIC ULCERATION, vomiting.

Hemat: leukocytosis, THROMBOEMBOLISM, thrombophlebitis.

Metab: weight gain, weight loss.

MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain.

Neuro: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness.
Misc: (INCLUDING ANAPHYLAXIS)HYPERSENSITIVITY REACTIONS , INFECTION, KAPOSI'S SARCOMA.

Drug-Drug:

• Additive hypokalemia with thiazide and loop diuretics or amphotericin B.
• Hypokalemia may ↑ the risk of digoxin toxicity.
• May ↑ requirement for insulin or oral hypoglycemic agents.
• Phenytoin,phenobarbital, and rifampin↑ metabolism; may ↓ effectiveness.
• Oral contraceptives may ↓ metabolism.
• ↑risk of adverse GI effects with NSAIDs (including aspirin).
• At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines.

(Generic available)

• Tablets: 5 mg; 10 mg; 20 mg;
• Oral granules (Alkindi Sprinkle): 0.5 mg; 1 mg; 2 mg; 5 mg;
• Lyophilized powder for injection (sodium succinate): 100 mg/vial; 250 mg/vial; 500 mg/vial; 1 g/vial;
• Enema: 100 mg/60 mL;

• PO (Adults and Children >12 yr): 20–240 mg/day in 1–4 divided doses.
• PO (Children): Adrenocortical insufficiency/replacement therapy: 8–10 mg/m²/day in 2–3 divided doses; Anti-inflammatory or immunosuppressive: 2.5–10 mg/kg/day or 75–300 mg/m²/day in 3–4 divided doses.
• PO (Neonates): Congenital adrenal hyperplasia: 10–20 mg/m²/day in 3 divided doses.
• PO, IV (Neonates): Refractory hypoglycemia: 5 mg/kg/day divided every 8–12 hr or 1–2 mg/kg/dose every 6 hr.
• Rect (Adults): Retention enema: 100 mg nightly for 21 days or until remission occurs.
• IM, IV (Adults): 100–500 mg every 2–6 hr (range 100–8000 mg/day).
• IM, IV (Children and Infants): Adrenocortical insufficiency: 1–2 mg/kg/dose bolus, then 25–250 mg/day in divided doses every 6–8 hr. Anti-inflammatory or immunosuppressive: 1–5 mg/kg/day or 30–150 mg/m²/day divided every 12–24 hr; Physiologic replacement: 0.25–0.35 mg/kg/day or 12–15 mg/m²/day once daily;Shock: 50 mg/kg bolus then 50 mg/kg as a 24 hr infusion.
• IV (Neonates): Bronchopulmonary dysplasia prevention in preterm neonates with prenatal inflammatory exposure: 1 mg/kg/day divided every 12 hr during the first 2 wk of life; Refractory hypotension: 3 mg/kg/day divided every 8 hr x 5 days.

A-Hydrocort, Alkindi Sprinkle, Colocort, Cortef, Cortenema, Solu-CORTEF

• In pharmacologic doses, suppresses inflammation and the normal immune response.
• Has numerous intense metabolic effects (see Adverse Reactions and Side Effects).
• Suppresses adrenal function at chronic doses of 20 mg/day.
• Replaces endogenous cortisol in deficiency states.
• Also has potent mineralocorticoid (sodium-retaining) activity.

• Replacement therapy in adrenal insufficiency.
• Suppression of inflammation and modification of the normal immune response.

Therapeutic Classification: corticosteroids

Pharmacologic Classification: corticosteroids

Absorption: Well absorbed following oral administration. Sodium succinate salt is rapidly absorbed following IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete. IV administration results in complete bioavailability.

Distribution: Widely distributed to tissues.

Metabolism/Excretion: Metabolized mostly by the liver.

Half-life: 1.5–2 hr (plasma), 8–12 hr (tissue); adrenal suppression lasts 1.25–1.5 days.

(anti-inflammatory activity)

• Educate patient on reason for hydrocortisoneand side effects. Instruct them to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Do not share medication with others, even if they have similar symptoms; may be harmful. Advise patient to read Patient Information before starting and with each Rx refill in case of changes.
  • Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.
  • Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening. Medical ID should be worn in case of emergencies.
  • Advise patient to avoid grapefruit juice during therapy.
  • Advise patient that oral granules may be seen in stool.
  • Advise patient to notify health care professional of signs and symptoms of hypercorticism (acne; thicker or more hair on body and face; bruising easily; fatty pad or hump between shoulders [buffalo hump]; rounding of face [moon face]; pink or purple stretch marks on skin of abdomen, thighs, breasts, and arms; ankle swelling), adrenal suppression (tiredness, weakness, nausea and vomiting, low blood pressure), worsening of allergies (eczema, rhinitis), or infection (fever, chills, pain, feeling tired, aches, nausea and vomiting).
  • May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
  • Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur.
  • Corticosteroids cause immunosuppression and may mask symptoms of infection. May worsen existing tuberculosis; fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex. Notify health care professional immediately if exposed to chicken pox or measles.
  • Caution patient to avoid vaccinations without first consulting health care professional.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other medications, especially St. John's wort.
  • Pedi: Advise parents that use may cause shortened stature.
  • Instruct patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Hypoadrenalism may occur in infants born to mothers receiving corticosteroids during pregnancy. Observe infant for signs of hypoadrenalism (poor feeding, irritability, weakness, vomiting).
• Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see Appendix M). Alcohol should be avoided during therapy.
  • If rectal dose used >21 days, decrease to every other night for 2–3 wk to decrease gradually.

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