Hydrocortisone (Solu Cortef) or cortisol is a corticosteroid that is used to treat various inflammatory, immune-mediated, and allergic diseases.

Hydrocortisone (Solu Cortef) Uses:

• Allergic states:

  • Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in drug hypersensitivity reactions, serum sickness, transfusion reactions, perennial or seasonal allergic rhinitis, or acute noninfectious laryngeal edema (epinephrine is the drug of the first choice).

• Dermatologic diseases:

  • Atopic dermatitis;
  • contact dermatitis;
  • bullous dermatitis herpetiformis;
  • exfoliative dermatitis;
  • severe erythema multiforme (Stevens-Johnson syndrome);
  • exfoliative erythroderma;
  • pemphigus;
  • severe psoriasis;
  • severe seborrheic dermatitis;
  • mycosis fungoides.

• Edematous states:

  • To induce diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus.

• Endocrine disorders:

  • Acute adrenocortical insufficiency;
  • congenital adrenal hyperplasia;
  • nonsuppurative thyroiditis;
  • primary or secondary adrenocortical insufficiency;
  • hypercalcemia associated with cancer;
  • preoperatively and in the event of serious trauma or illness, in patients with known adrenal insufficiency or when the adrenocortical reserve is doubtful;
  • shock unresponsive to conventional therapy if adrenocortical insufficiency exists or is suspected.

• GI diseases:

  • To tide the patient over a critical period of the disease in ulcerative colitis and regional enteritis.

• Hematologic disorders:

  • Acquired (autoimmune) hemolytic anemia;
  • erythroblastopenia (RBC anemia);
  • immune thrombocytopenia (formerly known as idiopathic thrombocytopenic purpura) in adults;
  • congenital (erythroid) hypoplastic anemia (Diamond Blackfan anemia);
  • pure red cell aplasia;
  • select cases of secondary thrombocytopenia.

• Neoplastic diseases:

  • Palliative management of leukemias and lymphomas (adults);
  • acute leukemia of childhood.

• Nervous system:

  • Acute exacerbations of multiple sclerosis;
  • cerebral edema associated with a primary or metastatic brain tumor, or craniotomy.

Note: Treatment guidelines recommend the use of high-dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis.

• Ophthalmic diseases:

  • Severe acute and chronic allergic and inflammatory processes involving the eye, such as:
    • allergic conjunctivitis;
    • anterior segment inflammation;
    • chorioretinitis;
    • allergic corneal marginal ulcers;
    • diffuse posterior uveitis and choroiditis;
    • herpes zoster ophthalmicus;
    • optic neuritis;
    • sympathetic ophthalmia;
    • iritis and iridocyclitis;
    • keratitis;
    • other ocular inflammatory conditions unresponsive to topical corticosteroids.

• Respiratory diseases:

  • Aspiration pneumonitis;
  • bronchial asthma;
  • berylliosis;
  • idiopathic eosinophilic pneumonia;
  • Loeffler syndrome (not manageable by other means);
  • fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy;
  • symptomatic sarcoidosis.

• Rheumatic disorders:

  • As adjunctive therapy for short-term administration in:
    • acute and subacute bursitis,
    • acute gouty arthritis,
    • epicondylitis,
    • posttraumatic osteoarthritis,
    • acute nonspecific tenosynovitis,
    • ankylosing spondylitis psoriatic arthritis,
    • rheumatoid arthritis,
    • including juvenile rheumatoid arthritis,
    • synovitis of osteoarthritis;
    • during an exacerbation or as maintenance therapy in acute rheumatic carditis,
    • dermatomyositis (polymyositis),
    • temporal arteritis, and
    • systemic lupus erythematosus.

• Miscellaneous:

  • Trichinosis with neurologic or myocardial involvement;
  • tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy.

• Off Label Use of Hydrocortisone in Adults:

  • Septic shock
  • Thyroid storm
  • In-hospital cardiac arrest

Hydrocortisone (Solu Cortef) Dose in Adults

Note:

• Adjust dose depending upon the condition being treated and the response of the patient.
• The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.
• In life-threatening situations, parenteral doses larger than the oral dose may be needed.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute exacerbation of Asthma (off-label dose):

• Oral: 200 mg in divided doses for 5 to 7 days.

Hydrocortisone (Solu Cortef) Dose as an Anti-inflammatory or immunosuppressive:

• IM, IV: Initial: 100 to 500 mg per dose at intervals of 2, 4, or 6 hours.
• Oral: Initial: 20 to 240 mg every day.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute adrenal insufficiency (adrenal crisis) :

Note: Appropriate fluid resuscitation is also required.

• IV: 100 mg IV bolus given immediately, followed by 25 to 75 mg IV every 6 hours or 200 mg/24 hours as a continuous IV infusion for the first 24 hours.
• After the initial 24 hours, may gradually taper the dose; once the patient is stable, may resume oral maintenance dosing.

Hydrocortisone (Solu Cortef) Dose in the treatment of Chronic adrenal insufficiency (eg, primary, secondary, classic congenital adrenal hyperplasia) :

• Oral: 15 to 25 mg per day in 2 to 3 divided doses.
• Administer the largest dose in the morning upon awakening, followed by the next dose 2 hours after lunch (2-dose regimen) or next dose at lunch, followed by the smallest dose in the afternoon no later than 4 to 6 hours before bedtime (3-dose regimen).

Hydrocortisone (Solu Cortef) Dose in the treatment of Adrenal insufficiency (temporary), physiologic replacement following resection of an ACTH-producing tumor or unilateral adrenalectomy (off-label dose):

• Oral: 10 to 12 mg per m²  per day in 2 to 3 divided doses, with the first dose taken as soon as possible after waking;
• continue hydrocortisone until the HPA axis recovers, generally 6 to 12 months following resection of ACTH-producing tumors or 18 months following unilateral adrenalectomy.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute exacerbations of multiple sclerosis:

Note: Treatment guidelines recommend the use of high-dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis.

• IM, IV: 800 mg per day for 7 days, followed by 320 mg every other day for 1 month.
• Oral: 200 mg per day for 7 days, followed by 80 mg every other day for 1 month.
• Stress dosing in patients known to be adrenally-suppressed (ie, prevention of adrenal crisis in glucocorticoid-treated patients) (off-label dose):

Hydrocortisone (Solu Cortef) Dose during Sickness:

• Illness with fever: Oral:

  • Double the routine oral hydrocortisone dose until recovery for fever more than 38°C [100.4°F] or triple the routine oral hydrocortisone dose until recovery for fever more than 39°C [102.2°F]; return to standard dose within 1 to 2 days.

Hydrocortisone (Solu Cortef) Dose in the treatment of Gastroenteritis with vomiting and/or diarrhea:

• IM, SubQ: 100 mg dose given early in course of illness;
• repeat after 6 to 12 hours.

Hydrocortisone (Solu Cortef) Dose in the treatment of Severe infection (eg, pneumonia with altered cognition):

• IM, SubQ: 100 mg dose given early in course of illness;
• repeat after 6 to 12 hours until recovery.

Hydrocortisone (Solu Cortef) Dose in Surgery:

• Minor stress (ie, inguinal herniorrhaphy):

  • IV: 25 mg per day for 1 day.

• Moderate stress (ie, joint replacement, cholecystectomy):

  • IV: 50 to 75 mg per day (25 mg every 8 to 12 hours) for 1 to 2 days.

• Major stress (pancreatoduodenectomy, esophagogastrectomy, cardiac surgery):

  • IV: 100 to 150 mg per day (50 mg every 8 to 12 hours) for 2 to 3 days.

Hydrocortisone (Solu Cortef) Dose in the treatment of Septic shock (off-label):

Note: Corticosteroids should only be used for the septic shock that is not responsive to volume resuscitation and vasopressors.

• IV: 50 mg bolus every 6 hours, either as monotherapy or in combination with fludrocortisone or
• 200 mg/day as a continuous infusion.
• Guidelines suggest a therapy duration of ≥3 days; most studies treated for up to 7 days; not all studies tapered therapy.
• May consider a slow taper over several days when vasopressors are no longer required to avoid possible hemodynamic deterioration which may occur with abrupt withdrawal.

Note:

• Low-dose hydrocortisone in septic shock patients may cause a significant increase in hyperglycemia and hypernatremia.
• A small study demonstrated that repetitive bolus doses of hydrocortisone caused significant hyperglycemia that was not seen during continuous infusion
• practice guidelines recommend strategies for avoidance and/or detection of these side effects, such as dosing by continuous infusion.

Hydrocortisone (Solu Cortef) Dose in the treatment of Thyroid storm (off-label):

• IV: 300 mg loading dose, followed by 100 mg every 8 hours.

Hydrocortisone (Solu Cortef) Dose in Childrens

Note:

• Adjust dose depending upon the condition being treated and the response of the patient.
• The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.
• In life-threatening situations, parenteral doses larger than the oral dose may be required.

Hydrocortisone (Solu Cortef) Dose in the treatment of Acute Adrenal Insufficiency (adrenal crisis):

• Dosage regimens variable: IM, IV (preferred):

  • Weight-directed: Limited data available:

    • Infants, Children, and Adolescents:
      • Initial: 2 to 3 mg per kg;
      • maximum dose: 100 mg per dose;
      • then for infants: 1 to 5 mg per kg per dose every 6 hours;
      • for children and adolescents, see BSA- or age-directed dosing; may also be administered I.O. if necessary.

  • BSA-directed dosing: Limited data available:

    • Infants, Children, and Adolescents:
      • Initial: 50 to 100 mg per m² once followed by 50 to 100 mg per m² per day in 4 divided doses.

  • Age-directed dosing (fixed dosing): Limited data available:

    • Infants:
      • 10 to 25 mg once followed by 10 to 25 mg/day in divided doses every 6 hours for 24 hours then subsequent dose reductions and rate determined by patient response
    • Children <5 years (eg, young children):
      • 25 to 50 mg once followed by 25 to 50 mg per day in divided doses every 6 hours for 24 hours then subsequent dose reductions and rate determined by patient response
    • Children ≥5 years (eg, older children):
      • 50 to 100 mg once followed by 50 mg per day in divided doses every 6 hours for 24 hours then subsequent dose reductions and rate determined by patient response
    • Adolescents:
      • 100 mg once followed by 100 mg per day in divided doses every 6 hours for 24 hours then subsequent dose reduction and rate determined by patient response

Hydrocortisone (Solu Cortef) Dose as Anti-inflammatory or immunosuppressive:

Note: Dosing range variable; individualize dose for disease state and patient response.

• Infants and Children:

  • Oral: 2.5 to 10 mg per kg per day or 75 to 300 mg per m²  per day divided every 6 to 8 hours.
  • IM, IV:
    • Manufacturer's labeling:
      • Initial: 0.56 to 8 mg/kg/day or 20 to 240 mg/m²/day in 3 or 4 divided doses
    • Alternate dosing: Limited data available:
      • 1 to 5 mg/kg/day or 30 to 150 mg/m²/day divided every 12 to 24 hours.

• Adolescents:

  • Oral, IM, IV, SubQ:
    • 15 to 240 mg every 12 hours.

Hydrocortisone (Solu Cortef) Dose in the treatment of Congenital adrenal hyperplasia:

• Infants, Children, and Adolescents: AAP Recommendations:

Note:

• Administer the morning dose as soon as possible.
• Tablets may result in more reliable serum concentrations than oral liquid formulation;
• Use of oral suspension is not recommended.
• Individualize dose by monitoring growth, hormone levels, and bone age; mineralocorticoid (eg, fludrocortisone) and sodium supplement may be required in salt losers.
  • Initial: Oral (tablets):
    • 10 to 15 mg/m²/day in 3 divided doses;
    • higher initial doses (20 mg/m²/day) may be required to achieve initial target hormone serum concentrations.
  • Maintenance dose: Oral (tablets): Usual requirement:
    • Infants:
      • 5 to 5 mg/dose  thrice in a day,
    • Children:
      • 5 to 10 mg/dose thrice in a day.
    • Adolescents (fully grown):
      • 15 to 25 mg/day divided in 2 to 3 each day doses

Hydrocortisone (Solu Cortef) Dose in the Physiologic replacement:

• Infants and Children:

  • Oral: 8 to 10 mg/m²/day divided every 8 hours;
  • up to 12 mg/m²/day in some patients;
  • To replicate diurnal variation, the highest doses are typically administered in the morning and midday dose with the lower dose in the evening.

Hydrocortisone (Solu Cortef) Dose as supplemental for Stress dosing: Limited data available; dosage regimens variable:

• Infants, Children, and Adolescents:

Note:

• Dosing based on the level of physiological stress related to the condition, the dose should be individualized based on the patient and continued until resolution of the stressful condition (usually 24 to 48 hours).
• Typically, supplementation for emotional or minimal physiological stress conditions or prior to exercise is not necessary.
• Dosing is generally 2 to 3 times physiologic replacement level.

  • BSA-directed dosing: Oral, IM, IV:

    • Mild to moderate stress:
      • 20 to 50 mg/m²/day divided into 3 or 4 doses;
      • doses on the lower end of the range (20 to 30 mg/m²/day) may be divided twice daily
    • Major stress or surgery:
      • 100 mg per m²  per day in divided doses every 6 hours
    • Planned surgery:
      • Pre-anesthesia of 50 mg/m² IV or IM administered 30 to 60 minutes prior to surgery followed by a second dose of 50 mg/m² as a continuous IV infusion or in divided doses every 6 hours for at least 24 hours

  • Age-directed for moderate stress in patients with congenital adrenal hyperplasia:

    • Infants and preschool children:
      • IV: Initial dose: 25 mg once, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose in divided doses every 6 hours
    • School-age children:
      • IV: Initial dose: 50 mg once in a day, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose in divided doses every 6 hours
    • Adolescents:
      • IV: Initial dose: 100 mg once, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose in divided doses every 6 hours

Hydrocortisone (Solu Cortef) Dose in the Septic shock; catecholamine-refractory with suspected/proved adrenal insufficiency: Limited data available:

• Infants, Children, and Adolescents:

  • IV: 50 to 100 mg/m²/day; in some cases, doses may be titrated up to 50 mg/kg/day if necessary for shock reversal; however, efficacy data variable with the higher doses.

Solu Cortef (Hydrocortisone) Pregnancy Risk Factor: C

• Corticosteroids have been linked to adverse events in animal reproduction studies.
• Hydrocortisone is the best corticosteroid for treating adrenal insufficiency during pregnancy.
• As the pregnancy progresses, it is possible for doses to be adjusted and that stress doses may be necessary during active labor.
• Women with adrenal insufficiency during pregnancy should be checked at least once per trimester.
• There have been some studies that show an association between oral clefts and systemic corticosteroid usage in the first trimester.
• However, this information is contradictory and could be affected by maternal indications for use.
• Monitor for hypoadrenalism in newborns after maternal use of corticosteroids during pregnancy.
• Uncontrolled asthma can lead to adverse pregnancy events (increased chance of perinatal death, preeclampsia and preterm births, low birth weight infants).
• Poorly managed asthma or exacerbations of asthma may pose a greater risk to the fetus/maternal health than medications that are properly used.
• For the treatment of asthma in pregnancy, it is recommended to use inhaled corticosteroids.
• However, systemic corticosteroids should also be used to treat severe persistent asthma or acute exacerbations.
• Systemic corticosteroids should be administered to women with asthma who are pregnant or have just given birth. This will prevent adrenal crises.
• It is recommended that systemic corticosteroids be used in pregnancy to treat rheumatic diseases.
• This means that the maximum effective dose should be taken for the longest time possible.
• Systemic corticosteroids should not be used as an initial treatment for dermatologic conditions in pregnant women.
• They should be avoided during the first trimester and only used at the lowest dose.

Hydrocortisone use during breastfeeding:

• Breast milk contains corticosteroids.
• Manufacturer notes that systemic maternal use of corticosteroids can cause adverse effects in breastfed babies (eg, growth suppression or interference with endogenous corticosteroid manufacturing).
• When used in their usual doses, corticosteroids can be tolerated by breastfeeding women.
• However, it is recommended that the infant be monitored (WHO 2002).
• Based on a study with prednisolone, some guidelines suggest waiting for 4 hours after the maternal dose to reduce the risk of exposure to the infant.
• Hydrocortisone is safe for breastfeeding women if taken in single doses. However, data on prolonged use are not available.

Hydrocortisone (Solu Cortef) Dose in Kidney disease:

Manufacturer's labeling doesn't provide any dosage adjustments; use with caution.

Hydrocortisone (Solu Cortef) Dose in Liver disease:

Manufacturer's labeling doesn't provide any dosage adjustments; use with caution.

Side effects of Hydrocortisone (Solu Cortef):

• Cardiovascular:

  • Cardiac Arrhythmia
  • Cardiac Failure (Especially In Susceptible Patients)
  • Cardiomegaly
  • Circulatory Shock
  • Hypertension
  • Hypertrophic Cardiomyopathy (Premature Infants)
  • Atheromatous Embolism
  • Bradycardia
  • Myocardial Rupture (Post-Myocardial Infarction)
  • Syncope
  • Tachycardia
  • Thromboembolism
  • Thrombophlebitis
  • Vasculitis

• Central Nervous System:

  • Emotional Lability
  • Euphoria
  • Headache
  • Increased Intracranial Pressure (With Pseudotumor Cerebri; Usually Following Discontinuation)
  • Insomnia
  • Malaise
  • Arachnoiditis (Intrathecal Administration)
  • Depression
  • Meningitis (Intrathecal Administration)
  • Myasthenia
  • Neuritis
  • Neuropathy
  • Paraplegia (Intrathecal Administration)
  • Paresthesia
  • Personality Changes
  • Psychic Disorder
  • Seizure
  • Sensory Disturbance (Intrathecal Administration)
  • Tingling Of Skin (Especially In The Perineal Area After IV Injection)
  • Vertigo

• Dermatologic:

  • Alopecia
  • Atrophic Striae
  • Burning Sensation Of Skin (Especially In The Perineal Area After IV Injection)
  • Diaphoresis
  • Ecchymosis
  • Erythema (Including Facial)
  • Exfoliation Of Skin
  • Acne Vulgaris
  • Allergic Dermatitis
  • Hyperpigmentation
  • Hypertrichosis
  • Hypopigmentation
  • Skin Atrophy
  • Skin Rash
  • Suppression Of Skin Test Reaction
  • Urticaria
  • Xeroderma

• Endocrine & Metabolic:

  • Diabetes Mellitus (Latent)
  • Fluid Retention
  • Glycosuria
  • Growth Suppression
  • Hirsutism
  • Adrenal Suppression
  • Cushing Syndrome
  • HPA-Axis Suppression
  • Hypercalcemia (Associated With Cancers)
  • Hyperglycemia (Including Increased Requirements For Insulin Or Oral Hypoglycemic Agents In Diabetes Mellitus)
  • Hypokalemia
  • Hypokalemic Alkalosis
  • Impaired Glucose Tolerance
  • Lipodystrophy
  • Lipomatosis (Epidural)
  • Menstrual Disease (Menstrual Irregularities)
  • Moon Face
  • Negative Nitrogen Balance
  • Protein Catabolism
  • Sodium Retention
  • Weight Gain

• Gastrointestinal:

  • Gastrointestinal Disease (Intrathecal Administration)
  • Gastrointestinal Perforation (Small And Large Intestine
  • Particularly In Patients With Inflammatory Bowel Disease)
  • Hiccups
  • Increased Appetite
  • Nausea
  • Pancreatitis
  • Abdominal Distention
  • Carbohydrate Intolerance
  • Dyspepsia
  • Peptic Ulcer (With Possible Perforation And Hemorrhage)
  • Ulcerative Esophagitis
  • Vomiting

• Genitourinary:

  • Asthenospermia
  • Bladder Dysfunction (Intrathecal Administration)

• Hematologic & Oncologic:

  • Leukocytosis
  • Petechia

• Hepatic:

  • Hepatomegaly
  • Increased Serum Transaminases (Usually Mild Elevations And Reversible On Discontinuation)

• Hypersensitivity:

  • Anaphylaxis
  • Angioedema
  • Hypersensitivity Reaction

• Infection:

  • Increased Susceptibility To Infection
  • Infection
  • Sterile Abscess

• Local:

  • Atrophy At Injection Site (Cutaneous And Subcutaneous)
  • Postinjection Flare (Intra-Articular Use)
  • Skin Edema

• Neuromuscular & Skeletal:

  • Osteoporosis
  • Pathological Fracture (Long Bones)
  • Rupture Of Tendon (Particularly Achilles Tendon)
  • Steroid Myopathy
  • Amyotrophy
  • Charcot-Like Arthropathy
  • Lower Extremity Weakness (Intrathecal Administration)
  • Osteonecrosis (Aseptic Necrosis Of Femoral And Humoral Heads)
  • Vertebral Compression Fracture

• Ophthalmic:

  • Exophthalmos
  • Glaucoma
  • Increased Intraocular Pressure
  • Cataract (Posterior Subcapsular)
  • Retinopathy (Central Serous Chorioretinopathy)

• Respiratory:

  • Pulmonary Edema

• Miscellaneous:

  • Wound Healing Impairment

Contraindications to Hydrocortisone (Solu Cortef):

• Hypersensitivity to hydrocortisone and any component of the formulation
• systemic fungal infections;
• Patients with idiopathic thrombocytopeniapurpura may require intramuscular injections.
• Use in infants who are premature (formulations containing only benzyl alcohol);
• Intrathecal administration
• Live or attenuated vaccines against viruses (with immunosuppressive corticosteroids).

Canadian labeling: Additional contraindications not in US labeling

• Herpes simplex eye infection (except for emergency or short-term therapy);
• Varicella and vaccinia are not recommended for emergency or short-term therapy.

Warnings and precautions

• Suppression of the adrenals:

  • An adrenal crisis may result from HPA axis suppression.
  • It is important to withdraw and stop using a corticosteroid slowly and carefully.
  • Patients who are being transferred from systemic to inhaled corticosteroids must be careful.
  • This is because of possible adrenal insufficiency, withdrawal from steroids, and can cause an increase in allergy symptoms.
  • May cause hypercortisolism or suppression of the hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods.
  • Patients who are taking more than 20 mg of prednisone or equivalent daily may be at greatest risk.
  • Tragic events have been caused by adrenal insufficiency in asthmatic sufferers after and during transfer from systemic corticosteroids (or aerosol steroids) to systemic steroids. Aerosol steroids don't provide the systemic steroids needed to treat trauma, surgery, or other infections.

• Anaphylactoid reactions

  • Patients who have received corticosteroids have had rare cases of anaphylactic reactions.

• Dermal changes:

  • Avoid subcutaneous atrophy and deltoid muscles injection.
  • Avoid injecting or leaking into the dermis. Subdermal and/or dermal skin depression could occur at the injection site.

• Immunosuppression:

  • Avoid exposure to measles or chickenpox.
  • Corticosteroids shouldn't be used to treat cerebral malaria, fungal infections or viral hepatitis.
  • Patients with latent tuberculosis or TB reactivity require close observation.
  • Limit active TB use (fulminating and disseminated TB only) in conjunction with antituberculosis treatment.
  • Corticosteroids can increase the risk of secondary infections, mask acute infections (including fungal infections), prolong and exacerbate viral infections, as well as limit or preventive action against inactivated or killed vaccines.
  • Any patient who has recently traveled to tropical climates, or unexplained diarrhea should be excluded from corticosteroid initiation.
  • Strongyloides patients should be treated with extreme caution. Hyper infection, dissemination and even death have all been reported.

• Kaposi Sarcoma:

  • Kaposi Sarcoma can be caused by prolonged treatment with corticosteroids (case reports). If this is the case, it should be discontinued.

• Myopathy

  • High dose corticosteroids have been linked to acute myopathy in patients with neuromuscular transmission disorder.
  • Monitor creatine kinase; may affect ocular or respiratory muscles; recovery can be delayed

• Psychiatric disorders:

  • Corticosteroid treatment can worsen pre-existing mental conditions.
  • Corticosteroid abuse can cause psychotic manifestations such as mood swings, euphoria and personality changes.

• Cardiovascular disease

  • Take care after acute MI. Corticosteroids have been linked to myocardial injury.
  • Patients with hypertension and HF should be cautious. Fluid retention, electrolyte disturbances and hypertension have been reported to occur.

• Diabetes:

  • Use corticosteroids with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.

• Gastrointestinal Disease:

  • Patients with GI disorders (diverticulitis or fresh intestinal anastomoses or ulcerative colitis), should be cautious due to the risk of perforation.

• Head injury

  • Patients receiving IV methylprednisolone at high doses were more likely to die. High-dose corticosteroids are not recommended for head injuries.

• Hepatic impairment

  • Patients with cirrhosis or hepatic impairment should be cautious. Long-term fluid retention has been reported.

• Myasthenia gravis:

  • Patients with myasthenia Gravis should be cautious.
  • Exacerbations of symptoms have been reported, especially after initial treatment with corticosteroids.

• Ocular disease:

  • Acute optic neuritis can be treated with oral steroids.
  • However, this treatment may cause an increase in the number of episodes. It does not have any effect on visual outcomes.
  • Patients with ocular simplex should be cautious; corneal perforation can occur. Do not use in active ocular simplex.
  • Patients with cataracts or glaucoma should be cautious; patients who have experienced increased intraocular pressure, open angle glaucoma, and cataracts from prolonged use of the device should be advised.
  • Routine eye exams are recommended for chronic users.

• Osteoporosis

  • Patients with osteoporosis should be cautious with corticosteroids. High doses and long-term use have been linked to increased bone loss and fractures.

• Pheochromocytoma:

  • Pheochromocytoma crise has been reported using corticosteroids (may prove fatal).
  • Before administering corticosteroids to patients with suspected pheochromocytoma, it is important to consider the possibility of developing a pheochromocytoma crises.

• Renal impairment

  • Patients with impaired renal function should be cautious; fluid retention could occur.

• Seizure disorders:

  • Patients with seizure disorders should be cautious when using corticosteroids. Seizures have been associated with adrenal crisis.

• Sepsis or septic shock syndrome:

  • In the absence of shock, corticosteroids should be avoided for treating sepsis.

• Thyroid disease:

  • Thyroid status changes may require dosage adjustments.
  • The metabolic clearance of corticosteroids is higher in hyperthyroid patients than in hypothyroid.

Hydrocortisone (systemic): Drug Interaction

Risk Factor C (Monitor therapy)
Acetylcholinesterase Inhibitors	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur.
Amphotericin B	Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B.
Androgens	Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
Bile Acid Sequestrants	May decrease the absorption of Corticosteroids (Oral).
Calcitriol (Systemic)	Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic).
Coccidioides immitis Skin Test	Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test.
Corticorelin	Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy.
CYP3A4 Inducers (Strong)	May decrease the serum concentration of Hydrocortisone (Systemic).
CYP3A4 Inhibitors (Strong)	May increase the serum concentration of Corticosteroids (Systemic).
Deferasirox	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Deferasirox	Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Denosumab	May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased.
DilTIAZem	May increase the serum concentration of Corticosteroids (Systemic).
Erdafitinib	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Estrogen Derivatives	May increase the serum concentration of Corticosteroids (Systemic).
Indacaterol	May enhance the hypokalemic effect of Corticosteroids (Systemic).
Isoniazid	Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid.
Loop Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics.
Lumacaftor	May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Nicorandil	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination.
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective).
Nonsteroidal Anti-Inflammatory Agents (Nonselective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).
Ocrelizumab	May enhance the immunosuppressive effect of Immunosuppressants.
P-glycoprotein/ABCB1 Inducers	May decrease the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inducers may also further limit the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
P-glycoprotein/ABCB1 Inhibitors	May increase the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of pglycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
Pidotimod	Immunosuppressants may diminish the therapeutic effect of Pidotimod.
Quinolones	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased.
Ranolazine	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Ritodrine	Corticosteroids may enhance the adverse/toxic effect of Ritodrine.
Salicylates	May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity.
Sargramostim	Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim.
Siponimod	Immunosuppressants may enhance the immunosuppressive effect of Siponimod.
Somatropin	Corticosteroids (Systemic) may diminish the therapeutic effect of Somatropin.
Tacrolimus (Systemic)	Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase.
Tertomotide	Immunosuppressants may diminish the therapeutic effect of Tertomotide.
Thiazide and Thiazide-Like Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Trastuzumab	May enhance the neutropenic effect of Immunosuppressants.
Urea Cycle Disorder Agents	Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range.
Warfarin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin.
Risk Factor D (Consider therapy modification)
Antacids	May decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects.
Aprepitant	May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment.
Axicabtagene Ciloleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity.
Baricitinib	Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted.
Cosyntropin	Hydrocortisone (Systemic) may diminish the diagnostic effect of Cosyntropin. Management: Patients receiving hydrocortisone should omit their pre-test dose on the day selected for cosyntropin testing.
Desirudin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation.
Echinacea	May diminish the therapeutic effect of Immunosuppressants.
Fingolimod	Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections).
Fosaprepitant	May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect.
Hyaluronidase	Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required.
Leflunomide	Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly.
Mitotane	May decrease the serum concentration of Corticosteroids (Systemic).
Neuromuscular-Blocking Agents (Nondepolarizing)	May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur.
Nivolumab	Immunosuppressants may diminish the therapeutic effect of Nivolumab.
Roflumilast	May enhance the immunosuppressive effect of Immunosuppressants.
Sipuleucel-T	Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy.
Tisagenlecleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome).
Tofacitinib	Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants.
Vaccines (Inactivated)	Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation.
Vaccines (Live)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided.
Risk Factor X (Avoid combination)
Aldesleukin	Corticosteroids may diminish the antineoplastic effect of Aldesleukin.
BCG (Intravesical)	Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical).
Cladribine	May enhance the immunosuppressive effect of Immunosuppressants.
Desmopressin	Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin.
Indium 111 Capromab Pendetide	Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide.
Macimorelin	Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin.
Mifamurtide	Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide.
MiFEPRIStone	May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (e.g., for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment.
Natalizumab	Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased.
Pimecrolimus	May enhance the adverse/toxic effect of Immunosuppressants.
Tacrolimus (Topical)	May enhance the adverse/toxic effect of Immunosuppressants.

Hydrocortisone (systemic): Drug Interaction

Risk Factor C (Monitor therapy)
Acetylcholinesterase Inhibitors	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur.
Amphotericin B	Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B.
Androgens	Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
Bile Acid Sequestrants	May decrease the absorption of Corticosteroids (Oral).
Calcitriol (Systemic)	Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic).
Coccidioides immitis Skin Test	Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test.
Corticorelin	Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy.
CYP3A4 Inducers (Strong)	May decrease the serum concentration of Hydrocortisone (Systemic).
CYP3A4 Inhibitors (Strong)	May increase the serum concentration of Corticosteroids (Systemic).
Deferasirox	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Deferasirox	Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Denosumab	May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased.
DilTIAZem	May increase the serum concentration of Corticosteroids (Systemic).
Erdafitinib	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Estrogen Derivatives	May increase the serum concentration of Corticosteroids (Systemic).
Indacaterol	May enhance the hypokalemic effect of Corticosteroids (Systemic).
Isoniazid	Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid.
Loop Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics.
Lumacaftor	May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Nicorandil	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination.
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective).
Nonsteroidal Anti-Inflammatory Agents (Nonselective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).
Ocrelizumab	May enhance the immunosuppressive effect of Immunosuppressants.
P-glycoprotein/ABCB1 Inducers	May decrease the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inducers may also further limit the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
P-glycoprotein/ABCB1 Inhibitors	May increase the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of pglycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
Pidotimod	Immunosuppressants may diminish the therapeutic effect of Pidotimod.
Quinolones	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased.
Ranolazine	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Ritodrine	Corticosteroids may enhance the adverse/toxic effect of Ritodrine.
Salicylates	May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity.
Sargramostim	Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim.
Siponimod	Immunosuppressants may enhance the immunosuppressive effect of Siponimod.
Somatropin	Corticosteroids (Systemic) may diminish the therapeutic effect of Somatropin.
Tacrolimus (Systemic)	Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase.
Tertomotide	Immunosuppressants may diminish the therapeutic effect of Tertomotide.
Thiazide and Thiazide-Like Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Trastuzumab	May enhance the neutropenic effect of Immunosuppressants.
Urea Cycle Disorder Agents	Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range.
Warfarin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin.
Risk Factor D (Consider therapy modification)
Antacids	May decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects.
Aprepitant	May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment.
Axicabtagene Ciloleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity.
Baricitinib	Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted.
Cosyntropin	Hydrocortisone (Systemic) may diminish the diagnostic effect of Cosyntropin. Management: Patients receiving hydrocortisone should omit their pre-test dose on the day selected for cosyntropin testing.
Desirudin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation.
Echinacea	May diminish the therapeutic effect of Immunosuppressants.
Fingolimod	Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections).
Fosaprepitant	May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect.
Hyaluronidase	Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required.
Leflunomide	Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly.
Mitotane	May decrease the serum concentration of Corticosteroids (Systemic).
Neuromuscular-Blocking Agents (Nondepolarizing)	May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur.
Nivolumab	Immunosuppressants may diminish the therapeutic effect of Nivolumab.
Roflumilast	May enhance the immunosuppressive effect of Immunosuppressants.
Sipuleucel-T	Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy.
Tisagenlecleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome).
Tofacitinib	Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants.
Vaccines (Inactivated)	Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation.
Vaccines (Live)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided.
Risk Factor X (Avoid combination)
Aldesleukin	Corticosteroids may diminish the antineoplastic effect of Aldesleukin.
BCG (Intravesical)	Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical).
Cladribine	May enhance the immunosuppressive effect of Immunosuppressants.
Desmopressin	Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin.
Indium 111 Capromab Pendetide	Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide.
Macimorelin	Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin.
Mifamurtide	Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide.
MiFEPRIStone	May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (e.g., for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment.
Natalizumab	Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased.
Pimecrolimus	May enhance the adverse/toxic effect of Immunosuppressants.
Tacrolimus (Topical)	May enhance the adverse/toxic effect of Immunosuppressants.

Monitoring parameters:

• Serum glucose,
• electrolytes;
• blood pressure,
• weight,
• presence of infection;
• monitor IOP with therapy more than 6 weeks;
• bone mineral density;
• assess HPA axis suppression (eg, morning plasma cortisol test, ACTH stimulation test, urinary free cortisol test);
• growth in pediatric patients.

How to administer Hydrocortisone (Solu Cortef)?

Oral:

• Administer with food or milk to decrease GI upset.

Parenteral:

• For IM or IV administration:
  • Dermal and/or subdermal skin depression may occur at the injection site.

IM:

• • Avoid injection into the deltoid muscle (high incidence of subcutaneous atrophy).

IV bolus:

• • Administer undiluted over at least 30 seconds; for large doses (≥500 mg), administer over 10 minutes.

IV intermittent infusion:

• • Further dilute in a compatible fluid and administer over 20 to 30 minutes.

Mechanism of action of Hydrocortisone (Solu Cortef):

• It is a corticosteroid that acts quickly and has minimal sodium retention potential.
• It reduces inflammation through suppression of the migration of polymorphonuclear lymphocytes and reverses increased capillarypermeability.

The onset of action:

• IV: 1 hour

Absorption:

• Rapid

Bioavailability:

• Oral: 96 percent  ± 20 percent.

Protein binding:

• IV: 92 percent  ± 2 percent

Metabolism:

• Hepatic

Half-life elimination:

• IV: 2 ± 0.3 hours;
• Oral: 1.8 ± 0.5 hours.

Time to peak, plasma:

• Oral: 1.2 ± 0.4 hours.

Excretion:

• Urine.

International Brand Names of Hydrocortisone:

• Cortef
• Solu-CORTEF
• Cortifoam
• Cortin
• Cortis-100
• Cortisol
• Cortisol L.C.H.
• Cortisona
• Covocort
• Dhartisone100
• Drosodin
• Efcorlin
• Entofoam
• Fartison
• Flebocortid
• Flemex
• Actocortina
• Aftasone
• Arvisone
• Biocort
• Cipcorlin
• Clovisone
• Colifoam
• Colofoam
• Corhydron
• Coripen
• Cort-S
• Cortaject
• Cortef
• Fridalit
• Harond
• Hidrocort
• Hidrocortif
• Hidrocortizon
• Hidrotisona
• Hison
• Hycort
• Hycortil
• Hydrocort
• Hydrocortistab
• Hydrosone
• Hydrotopic
• Hyson
• Hysone
• Kortef
• Lyo-Cortin
• M-Cort
• Nositrol
• Oralsone
• Plenadren
• Primacor
• Primacort
• Rapicort
• Rapison
• Rolak
• Samcort
• Saxizon
• Solhidrol
• Solu Cortef
• Solu-Cortef
• Solu-Tisone
• Stericort
• Unicort
• Zonac
• Zycort

Hydrocortisone Brand Names in Pakistan:

Hydrocortisone Injection 100 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
Cortisol	Bio Pharma
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hydro Sod Suc	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrocort	Akhai Pharmaceuticals.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.
Solu-Hydrocort	Haji Medicine Co.

Hydrocortisone Injection 200 Mg
Cortisol	Bio Pharma

Hydrocortisone Injection 250 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
H-Cortisone	Mediate Pharmaceuticals (Pvt) Ltd
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hydro Sod Suc	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrocort	Akhai Pharmaceuticals.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.
Solu-Hydrocort	Haji Medicine Co.
Solu-Hydrocort	Haji Medicine Co.

Hydrocortisone Injection 500 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
H-Cortisone	Mediate Pharmaceuticals (Pvt) Ltd
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.

Hydrocortisone Eye Drops 1 %W/V
Hydrocortisone	Lahore Chemical & Pharmaceutical Works (Pvt) Ltd

Hydrocortisone Oint 1 %W/W
Hycortisone	Mediceena Pharma (Pvt) Ltd.

Hydrocortisone Cream 1 %W/W
Clozole-H	Pearl Pharmaceuticals
Cortiderm	Valor Pharmaceuticals
Cortiderm	Valor Pharmaceuticals
Cutis-Hc	Derma Techno Pakistan
Gen-Cot	Biogen Pharma
Hydrocort 1.0%	Atco Laboratories Limited
Hydrocort 1.0%	Atco Laboratories Limited
Hydrocortisone	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrogray	Gray`S Pharmaceuticals
Hydroheal	Webros Pharmaceuticals
Hydrosone	Ferozsons Laboratoies Ltd.
Hydrovate	Pearl Pharmaceuticals

Hydrocortisone Cream 2 %W/W
Cortival	Valor Pharmaceuticals
Hydrosone	Ferozsons Laboratoies Ltd.

Hydrocortisone Cream 2.5 %W/W
Hydrocort 2.5%	Atco Laboratories Limited