Hydrocortisone
Solu-Cortef · Hydrokortison Takeda · Plenadren · Alkindi
Endogenous cortisol in pharmaceutical form and accordingly the first choice when the intention is substitution rather than immunosuppression. Unlike prednisolone, betamethasone, and dexamethasone, hydrocortisone has a clinically meaningful mineralocorticoid effect, which is the entire point in adrenocortical insufficiency — and the short duration allows the daily dose to be distributed to mimic the physiological cortisol pattern. Keep the three dose levels distinct: substitution, stress dose, and crisis.
In suspected Addisonian crisis, hydrocortisone 100 mg iv is given immediately together with sodium chloride — never await a cortisol result or an ACTH stimulation test. An untreated crisis is fatal within hours.
Dosing in adults
| Indication | Regimen | Comment |
|---|---|---|
| Substitution in adrenocortical insufficiency | 15–30 mg orally per day divided into 2–3 doses, largest dose in the morning | last dose in the early afternoon to avoid sleep disturbance |
| Stress dose in intercurrent illness | Double or triple the daily dose for 2–3 days | with fever above 38 °C or an infection requiring antibiotics |
| Stress dose for major surgery | 100 mg iv every 8 hours on the day of surgery, then 50 mg every 8 hours for 1–2 days | for intermediate surgery 25 mg iv every 8 hours is sufficient |
| Addisonian crisis | 100 mg iv as bolus, then 50–100 mg every 6–8 hours or 200 mg per day as infusion | give simultaneously 1 000 ml sodium chloride 9 mg/ml in the first hour |
| Vomiting or diarrhoea at home | 100 mg im with the patient's own emergency ampoule | all patients with adrenocortical insufficiency must have an ampoule and a steroid emergency card |
No dose adjustment in renal impairment. Monitor sodium, potassium, and blood pressure more carefully because the mineralocorticoid effect may cause fluid retention.
No established dose adjustment. Hydrocortisone is the active substance and requires no hepatic activation, making it preferable to cortisone in hepatic failure.
Substitution 8–12 mg/m² body surface area per day divided into 3 doses. Crisis: 50 mg/m² iv as bolus, or 25 mg for children under 3 years, 50 mg aged 3–12 years, and 100 mg over 12 years.
Do not use hydrocortisone when the aim is sustained, potent anti-inflammatory effect throughout the day — the duration is too short and the mineralocorticoid effect causes unnecessary sodium retention. Also do not switch substitution treatment to prednisolone or betamethasone without recognising that the mineralocorticoid effect is then lost and fludrocortisone must be added or adjusted.
Pharmacokinetics
- BIOAVAIL.
- approximately 95 % orally
- ONSET
- minutes iv; biological effect within 1–2 hours
- t½ (plasma)
- 1,5–2 hours
- BIOLOGICAL t½
- 8–12 hours
- EQUIVALENCE
- 20 mg = 5 mg prednisolone = 0,6 mg betamethasone
- MINERALOCORTICOID EFFECT
- Pronounced, dose-dependent
- PROTEIN BINDING
- approximately 90 % (cortisol-binding globulin)
- METABOLISM
- Hepatic, 11β-HSD and CYP3A4