Bedside Snapshot
  • What it is: Short-acting systemic glucocorticoid with some mineralocorticoid activity.
  • Primary jobs: Treat adrenal crisis; adjunct in refractory septic shock; adjunct in anaphylaxis; systemic steroid for severe asthma/COPD.
  • Onset: Rapid IV onset; genomic effects accrue over hours.
  • Typical ED/ICU dosing: 100 mg IV bolus for adrenal crisis; 200 mg/day in septic shock (e.g., 50 mg IV q6h).
Note: Steroids are adjuncts in anaphylaxis and septic shock — do not delay epinephrine or vasopressors.
Brand & Generic Names
  • Generic Name: Hydrocortisone
  • Brand Names: Solu-Cortef (hydrocortisone sodium succinate, IV/IM); oral hydrocortisone tablets
Medication Class

Short-acting systemic corticosteroid (glucocorticoid) with anti-inflammatory, immunomodulatory, and mild mineralocorticoid activity that can improve vascular responsiveness to catecholamines in adrenal insufficiency.

Pharmacology

Mechanism of Action:

  • Glucocorticoid receptor agonist → alters gene transcription to suppress pro‑inflammatory cytokines and mediators.
  • Stabilizes cellular and lysosomal membranes; decreases capillary permeability and edema.
  • Enhances vascular responsiveness to catecholamines; mineralocorticoid effect supports sodium/water retention in adrenal crisis.

Pharmacokinetics:

  • Route: IV/IM for sodium succinate (Solu‑Cortef); PO available.
  • Onset: Rapid with IV; genomic effects evolve over hours.
  • Half‑life: ~1.5–3 hours (biologic effects longer due to genomic modulation).
  • Elimination: Hepatic metabolism; renal excretion of metabolites.
Indications
  • Adrenal insufficiency / adrenal crisis (stress‑dose steroid replacement).
  • Refractory septic shock despite fluids and vasopressors (ICU adjunct per guidelines).
  • Anaphylaxis (adjunct to epinephrine/antihistamines/bronchodilators).
  • Severe asthma/COPD exacerbation requiring systemic steroids.
Dosing & Administration

Available Forms:

  • Hydrocortisone sodium succinate for injection (Solu‑Cortef): 100 mg (Act‑O‑Vial), 250 mg, 500 mg, 1 g vials.
  • Oral hydrocortisone tablets (various strengths) for maintenance therapy.

Common Adult Dosing:

Indication Initial Dose Notes
Adrenal crisis 100 mg IV bolus Then 50–100 mg IV q6–8h or infusion per protocol; transition per endocrinology.
Refractory septic shock (adjunct) 200 mg/day IV Commonly 50 mg IV q6h or continuous infusion; start when persistent shock despite vasopressors.
Anaphylaxis (adjunct) 50–100 mg IV once Does not replace epinephrine; consider in biphasic risk or refractory symptoms.
Severe asthma/COPD 100 mg IV once Alternative to methylprednisolone in some protocols.
Contraindications

Contraindications:

  • Known serious hypersensitivity to hydrocortisone or formulation components.

Precautions:

  • Use caution in active uncontrolled infections; consider coverage if indicated.
  • May worsen hyperglycemia, fluid retention, hypertension, and mood changes; monitor appropriately.
  • Chronic use risks: adrenal suppression, immunosuppression, osteoporosis, myopathy; ED/ICU short courses lower risk.
  • Avoid live vaccines during high‑dose systemic steroid therapy.
Adverse Effects

Common:

  • Hyperglycemia, fluid retention/edema, mood changes/insomnia, GI upset.

Serious:

  • GI bleeding/ulceration (with high doses/NSAIDs), severe infection, psychosis, myopathy.
Special Populations
  • Renal impairment: No routine adjustment; monitor fluid status and electrolytes.
  • Hepatic impairment: Use lowest effective dose; monitor for prolonged effects.
  • Pregnancy/lactation: Use when benefits outweigh risks in emergent indications; compatible with breastfeeding in typical doses.
  • Older adults: Higher risk of hyperglycemia, delirium, infection — monitor closely.
Monitoring

Clinical: Hemodynamics (for septic shock), respiratory status, edema/volume status, mental status.

Laboratory: Glucose, electrolytes (Na⁺/K⁺), WBC differential; consider GI protection when risk factors present.

Clinical Pearls
Don’t delay in adrenal crisis: Give 100 mg IV promptly when suspected; then continue stress dosing.
Septic shock: Start hydrocortisone when shock persists despite adequate fluids and vasopressors.
Glycemic impact: Expect hyperglycemia; pair with glucose monitoring and insulin as needed.
References
  • 1. Surviving Sepsis Campaign. (2021). International guidelines for management of sepsis and septic shock. Crit Care Med. https://doi.org/10.1097/CCM.0000000000005337
  • 2. Solu‑Cortef (hydrocortisone sodium succinate) [Prescribing information]. (2023). Pfizer. https://labeling.pfizer.com/ShowLabeling.aspx?id=520
  • 3. StatPearls. (2024). Hydrocortisone. https://www.ncbi.nlm.nih.gov/books/NBK538164/
  • 4. Endocrine Society. (2016). Guideline on primary adrenal insufficiency. J Clin Endocrinol Metab. https://doi.org/10.1210/jc.2015-1710
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