Hydrocortisone (Solu-Cortef)

Stress-dose coverage - Given for adrenal insufficiency and perioperative stress-dose steroid replacement in patients on chronic steroids to prevent intraoperative adrenal crisis and refractory hypotension.

Refractory hypotension - Consider adrenal insufficiency when hypotension is unresponsive to fluids and vasopressors; empiric hydrocortisone can be diagnostic and therapeutic.

Glucose effect - Expect hyperglycemia; monitor and treat, especially in diabetics.

Mineralocorticoid activity - Unlike dexamethasone, hydrocortisone has meaningful mineralocorticoid effect useful when salt/volume retention is desired (primary adrenal insufficiency).

Drug Interactions - Enzyme inducers (rifampin, phenytoin) speed clearance; additive hypokalemia with diuretics; blunts response to insulin and oral hypoglycemics.

Pediatric Implications - Weight-based stress dosing (2 mg/kg, max 100 mg, then divided maintenance); neonates 4 mg/kg. Key agent for congenital adrenal hyperplasia.

Obstetric Implications - Category C; crosses the placenta but is largely inactivated by placental 11-beta-hydroxysteroid dehydrogenase, so it is preferred over dexamethasone when treating the mother rather than the fetus. Compatible with breastfeeding.

Relative:

Systemic fungal infection

Uncontrolled infection

Caution:

Diabetes

Poorly controlled hypertension/heart failure

Peptic ulcer disease

Stress-dose/adrenal insufficiency: 100 mg IV (adult); 2 mg/kg, max 100 mg (pediatric), then maintenance divided every 6 h. Major surgical stress up to 100 mg every 8 h.

Same doses may be given IM (Solu-Cortef).

Binds cytosolic glucocorticoid receptors to modulate transcription of anti-inflammatory and metabolic genes; also binds mineralocorticoid receptors producing sodium retention.

Hepatic

Renal

Solu-Cortef (succinate) is water-soluble for IV/IM use. Give IV push over 30 s to several minutes depending on dose.