Usual Adult Dose for Adrenocortical Insufficiency

Acute Adrenal Crisis:
100 mg IV followed by IV infusion of 200 mg over 24 hours OR 50 mg IV every 6 hours; then 100 mg IV the following day

Management of Primary Adrenal Insufficiency (PAI):
15 mg to 25 mg orally in 2 or 3 divided doses per day

• Highest dose should be given in the morning, then 2 hours after lunch (2-dose/day regimen) or at lunch and afternoon (3-dose/day regimen)

Prevention of Acute Adrenal Crisis:
Adjust dose according to severity of illness or magnitude of stressor

Comments:

• Fluid status should be managed according to protocols.
• Glucocorticoid replacement therapy should be adjusted based on clinical response.
• Most patients with PAI will require mineralocorticoid supplementation.
• Surgery and other stress inducing situations will require supplemental doses.

Suggested supplemental doses:

• Illness with fever: Double (fever greater than 100.4F [38C]) or triple (fever greater than 102.2F [39C]) oral hydrocortisone doses until recovery (usually 2 to 3 days); increase consumption of electrolyte-containing fluids as tolerated
• Not tolerating oral medication due to gastroenteritis or trauma: 100 mg IM
• Minor to moderate surgical stress: 25 to 75 mg per 24 hours for 1 to 2 days
• Major surgery with anesthesia, trauma, delivery, or ICU care: 100 mg IV followed by 200 mg IV infusion over 24 hours (or 50 mg IV/IM every 6 hours for 24 hours)

Use: For the treatment of adrenocortical insufficiency

Usual Adult Dose for Anti-inflammatory

Dosing should be individualized on the basis of disease and patient response

Oral:

• Initial dose: 20 mg to 240 mg orally per day

Parenteral:

• Initial dose: 100 mg to 500 mg IV or IM; may repeat doses at intervals of 2, 4, or 6 hours as indicated by response and clinical indication

Maintenance dose: After a favorable initial response, dose should be decreased in small amounts to the lowest dose that maintains an adequate clinical response; if a positive response is not achieved after a reasonable period of time, alternative therapy should be sought.

Comments:

• Lower doses, including doses lower than recommended doses, may suffice in less severe disease; doses in excess of recommended doses may be required in severe disease; in life-threatening situations, doses exceeding multiples of the oral dose may be justified.
• Patients should be closely monitored for signs requiring dose adjustments; if therapy is to be stopped after more than a few days, it should be gradually withdrawn.

Uses: For use when oral therapy is not feasible; it is used as a potent anti-inflammatory agent in managing disorders, diseases, and conditions affecting many organ systems including endocrine, dermatologic, ophthalmic, nervous. gastrointestinal, respiratory, musculoskeletal, and hematologic.

Usual Adult Dose for Sepsis

200 mg per day by continuous IV infusion

Recommendations from the International Guidelines for Management of Severe Sepsis and Septic Shock 2016:

• IV hydrocortisone should not be used if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability
• Steroids should not be used in septic patients to prevent septic shock as there is a lack of evidence to support this
• Continuous infusion is recommended over repetitive bolus injections as repetitive boluses have been shown to significantly increase blood glucose
• Taper hydrocortisone treatment when vasopressors no longer required

Use: For the treatment of septic shock when adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

Usual Adult Dose for Asthma

100 mg IV every 8 hours during surgical period; dose should be rapidly reduced within 24 hours after surgery

Comments:

• Asthma control should be assessed prior to surgery and if lung function is not well controlled, medications to improve lung function should be provided.
• For patients receiving oral corticosteroids in the 6 months prior to surgery, and for selected patients on high dose inhaled corticosteroids (ICS), IV hydrocortisone may be necessary to reduce risk for complications during and after surgery.
• Stress doses of corticosteroids may be considered for select patients with prior high-dose ICS use as clinically important adrenal suppression has been reported in these patients.

Use: To reduce risks of complications during and after surgery in patients with asthma.

Usual Adult Dose for Ulcerative Colitis

100 mg rectally (retention enema) nightly for 21 days or until both clinical and protological remission occurs

• Difficult cases may require 2 or 3 months of treatment

Comments:

• Clinical symptoms should subside within 3 to 5 days; improvement in appearance of the mucosa (as viewed by sigmoidoscopic exam) may lag behind; discontinue use if no improvement observed within 2 to 3 weeks.
• Some patients may require 2 to 3 months of therapy; if therapy lasts more than 21 days, do not stop abruptly
• Therapy has shown to benefit distal forms of ulcerative colitis including ulcerative proctitis, ulcerative proctosigmoiditis, and left-sided ulcerative colitis; it has been useful in some cases involving the transverse and ascending colons.

Use: As adjunctive therapy in the treatment of ulcerative colitis, especially distal forms.

Usual Adult Dose for Ulcerative Proctitis

1 applicatorful rectally once or twice daily for 2 to 3 weeks, then every second day thereafter

Comments:

• Satisfactory response generally occurs within 5 to 7 days with a marked decreased in symptoms; symptomatic improvement should be verified with sigmoidoscopy to best judge dose adjustment, duration of therapy, and rate of improvement.
• Therapy should be individualized and the proper maintenance dose determined by decreasing the initial dose in small decrements at appropriate time intervals until the lowest effective dose is reached.
• After long-term therapy, this drug should be gradually withdrawn.

Use: As adjunctive therapy in the topical treatment of ulcerative proctitis of the distal portion of the rectum in patients who cannot retain hydrocortisone or other corticosteroid enemas.

Usual Pediatric Dose for Adrenocortical Insufficiency

Acute Adrenal Crisis:
Initial dose: 2 to 3 mg/kg IV or intraosseous (IO) over 3 to 5 minutes; Maximum dose: 100 mg
Follow with:

• Infants: 1 to 5 mg/kg IV/IO every 6 hours
• Children: 12.5 mg/m2 IV/IO every 6 hours OR 50 mg/m2 IV followed by 50 to 100 mg/m2 IV in divided doses every 6 hours or via 24-hour continuous IV infusion

Management of Primary Adrenal Insufficiency (PAI):
Oral tablets: 8 mg/m2 orally in 3 or 4 divided doses per day

• Highest dose should be administered in morning

Oral granules: 8 to 10 mg/m2 (round to nearest 0.5 or 1 mg dose) orally in 3 divided doses

• Older children may have the dose divided into twice daily doses.
• When switching from oral tablets, use the same total daily dose.

Prevention of Acute Adrenal Crisis:
Adjust dose according to severity of illness or magnitude of stressor

Comments:

• It is important not to under dose during an adrenal crisis.
• Glucocorticoid replacement therapy should be adjusted based on clinical response including growth velocity, body weight, blood pressure, and energy levels.
• Most patients with PAI will require mineralocorticoid supplementation; infants will require up to 12 months of sodium chloride supplements.
• Surgery and other stress inducing situations will require supplemental doses.

Suggested supplemental doses:

• Illness with fever: Double (fever greater than 100.4F [38C]) or triple (fever greater than 102.2F [39C]) oral hydrocortisone doses until recovery (usually 2 to 3 days); increase consumption of electrolyte-containing fluids as tolerated
• Not tolerating oral medication due to gastroenteritis or trauma: 50 mg/m2 IM or estimate (e.g., infants: 25 mg; school-age: 50 mg; adolescents 100 mg)
• Minor to moderate surgical stress: 50 mg/m2 IM or double or triple oral replacement dose
• Major surgery with anesthesia, trauma, delivery, or ICU care: 50 mg/m2 IM followed by 50 to 100 mg/m2 IM in divided doses every 6 hours; rapidly taper and switch to oral regimen as soon as clinical state allows

Use: For the treatment of adrenocortical insufficiency

Usual Pediatric Dose for Anti-inflammatory

Dosing should be individualized on the basis of disease and patient response

• Initial dose: 0.56 to 8 mg/kg/day oral or IV in 3 or 4 divided doses (20 to 240 mg/m2/day)

Maintenance dose: After a favorable initial response, dose should be decreased in small amounts to the lowest dose that maintains an adequate clinical response; if a positive response is not achieved after a reasonable period of time, alternative therapy should be sought.

Comments:

• Lower doses, including doses lower than recommended doses, may suffice in less severe disease; doses in excess of recommended doses may be required in severe disease; in life-threatening situations, doses exceeding multiples of the oral dose may be justified.
• Patients should be closely monitored for signs requiring dose adjustments; if therapy is to be stopped after more than a few days, it should be gradually withdrawn.

Uses: For use as a potent anti-inflammatory agent in managing disorders, diseases, and conditions affecting many organ systems including endocrine, dermatologic, ophthalmic, nervous, gastrointestinal, respiratory, musculoskeletal, and hematologic.

Renal Dose Adjustments

Use with caution; no dose adjustments recommended

Liver Dose Adjustments

Use with caution; no dose adjustments recommended

Dose Adjustments

Elderly: The serious consequences of corticosteroid side effects should be carefully considered when initiating therapy.

Doses should be titrated based on patient response and severity of the condition; patients should be continuously monitored for signs that may require a dosage adjustment:

• Increased doses may be needed during periods of stress (e.g., surgery, infection, trauma) or, exacerbations of condition
• Dose reductions should occur once an adequate response is obtained
• If a beneficial response is not achieved within a couple of days, treatment should be discontinued and an alternative therapy considered.

Gradual discontinuation of therapy is warranted if therapy is to be stopped after more than a few days.

Approximate Equivalents (IV or oral formulations):
Hydrocortisone 20 mg is approximately equivalent to betamethasone 0.75 mg
Hydrocortisone 20 mg is approximately equivalent to dexamethasone 0.75 mg
Hydrocortisone 20 mg is approximately equivalent to methylprednisolone 4 mg
Hydrocortisone 20 mg is approximately equivalent to triamcinolone 4 mg
Hydrocortisone 20 mg is approximately equivalent to prednisolone 5 mg
Hydrocortisone 20 mg is approximately equivalent to prednisone 5 mg
Hydrocortisone 20 mg is approximately equivalent to cortisone 25 mg

Precautions

Consult WARNINGS section for additional precautions.

Safety and efficacy of rectal products have not been established in patients younger than 18 years.

Dialysis

Data not available

Other Comments

Administration advice:
Oral: Take with or after food to minimize stomach upset

• For the treatment of primary adrenocortical insufficiency, first dose should be taken in the morning at awakening and the last dose approximately 4 to 6 hours before bed

Parenteral: For IV or IM administration

• IV: Administer over 30 seconds (e.g., 100 mg) to 10 minutes (e.g., 500 mg or more); may also administer by IV infusion

Rectal Foam:

• Shake container vigorously for 5 to 10 seconds before use; do not remove container cap during use
• With container upright, gently place tip of applicator onto the nose of the container cap; pull plunger past fill line on the applicator barrel
• Fill applicator barrel by pressing down firmly on cap flanges, hold for 1 to 2 seconds and release; pause 5 to 10 seconds to allow foam to expand in barrel; repeat until foam reaches fill line; remove applicator from container cap (allow some foam to remain on applicator tip)
• Hold applicator firmly by barrel; gently insert tip into anus; once in place push plunger to expel foam, then withdraw applicator
• Apply to anus only with the enclosed applicator; do not insert any part of aerosol container directly into the anus
• Dissemble and rinse after each use to prevent foam build-up and possible blockage

Rectal (retention) Enema:

• Shake bottle well to ensure suspension is homogeneous
• Remove protective sheath from applicator tip; hold the bottle up so as not to lose any medication
• Assume correct body position (see illustrations on labeling)
• Insert lubricated applicator tip into rectum; it should tilt slightly towards back; squeeze slowly to instill medication
• Remain in position for at least 30 minutes to allow thorough distribution of medication; retain enema all night if possible

Storage requirements:

• Store at room temperature; do not refrigerate; do not autoclave as steroids are sensitive to heat
• Protect from light

Parenteral:

• Consult manufacturer product information for reconstitution and stability information
• Rectal Foam with applicator: Store upright; when used correctly the container will deliver a minimum of 14 applications

IV compatibility: Compatible with normal saline and dextrose solutions

General:

• High-dose corticosteroid therapy should continue only until condition has stabilized; hypernatremia may occur when continued beyond 48 to 72 hours and under such circumstances it may be desirable to switch to a steroid that cause less sodium retention (e.g., methylprednisolone).
• Hydrocortisone or cortisone acetate (in combination with fludrocortisone) are the preferred glucocorticoids for the treatment of primary adrenal insufficiency; prednisone or prednisolone may be considered in patients with reduced compliance, however longer acting glucocorticoids are not recommended due to the difficulty in dose titration and risk of Cushingoid side effects.
• Current treatment guidelines may be consulted for specific dose ranges.
• Corticosteroids confer palliative, symptomatic treatment by virtue of their anti-inflammatory effects; they are not curative.

Monitoring:

• For patients with primary adrenal insufficiency, therapeutic monitoring should be based on clinical response rather than hormonal monitoring (e.g., weight, postural blood pressure, energy levels, signs of frank glucocorticoid excess).
• Monitor growth velocity and development in pediatric patients
• Monitor intraocular pressure if therapy is continued for more than 6 weeks; regular eye exams should be encouraged
• Routine laboratory studies (including 2-hour postprandial blood glucose and serum potassium), blood pressure, weight, bone mineral density, and chest x-rays should be performed at regular intervals for patients on long-term corticosteroid therapy
• Monitor for hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing's syndrome, and hyperglycemia with chronic steroid users

Patient advice:

• Patients should understand that this drug should not be stopped abruptly or without medical advice; additionally, all healthcare professional providing care should be informed of their current and past corticosteroid use.
• Patients should understand that during times of stress, such as surgery or infection, additional supplementation doses may be necessary; they should discuss with their healthcare professional whether they need to carry a medical identification card that identifies their corticosteroid use.
• Patients on immunosuppressant doses of corticosteroids should understand that a greater risk of infection exists; they should avoid exposure to chickenpox or measles and if exposed, they should consult their healthcare professional promptly.
• Patients should check with their healthcare provider before receiving any vaccinations.
• Patients should be advised of common adverse reactions including changes in glucose tolerance, high blood pressure, behavioral/mood changes, increased appetite, and weight gain.

Frequently asked questions

• Can I use hydrocortisone cream on shingles rash?
• Can you put hydrocortisone cream on hemorrhoids?
• Can hydrocortisone cream be used on sunburn?
• What is the difference between hydrocortisone and cortisone?
• How long does it take for neomycin, polymyxin b and hydrocortisone ear drops to work?
• Can you use hydrocortisone cream on babies?
• Does hydrocortisone cream stop itching?