Hydrocortisone (Hydrocortisone)
Also sold as: Solucortef, Hydrocort, Efcorlin, Cortef
Pregnancy
Cat C
Lactation
Caution
Schedule
H
Forms
Tablet (10mg, 20mg) +6
Indications
- Adrenal crisis (acute) — emergency IV bolus
- Addison's disease (primary adrenal insufficiency) — replacement therapy
- Congenital adrenal hyperplasia (CAH) — replacement therapy
- Hypopituitarism (secondary adrenal insufficiency) — replacement
- Stress dosing (sick day rules) for adrenal insufficient patients
- Anaphylaxis (adjunct to epinephrine)
- Acute severe asthma (IV, hospital)
- Anti-inflammatory and immunosuppressive indications
- Dermatological conditions (mild eczema, dermatitis — topical)
- Haemorrhoids, proctitis (rectal foam)
Adult Dosing
Adrenal crisis (acute emergency)
100mg IV stat (bolus)
Then 50–100mg IV/IM every 6–8 hours for 24 hours; taper to oral once stable
Simultaneously: IV fluid resuscitation (0.9% NaCl); treat precipitating cause; dextrose if hypoglycaemia present
Addison's disease — physiological replacement
15–25mg/day in 2–3 divided doses
Lifelong; typically 10–15mg on waking + 5–10mg early afternoon
Mimic circadian cortisol pattern; largest dose on waking. Add fludrocortisone 0.05–0.2mg OD for mineralocorticoid replacement.
Sick day rules (doubled dose protocol)
Double or triple usual daily dose during illness, fever, or physical stress
During illness only; revert to normal when recovered
Triple dose for major surgery or trauma. Give IM injection kit for vomiting/unconsciousness.
Anaphylaxis (adjunct)
100–200mg IV
Single dose; repeat q4–6h if needed
Epinephrine is first-line; hydrocortisone reduces delayed biphasic reactions
Acute severe asthma (IV, hospital)
100mg IV q6h
Until oral therapy possible; switch to oral prednisolone 40–60mg OD
Use only when patient cannot take oral; no advantage over oral prednisolone bioavailability-wise if oral route available
Anti-inflammatory (systemic)
20–240mg/day in divided doses
Titrated to minimum effective dose; taper on discontinuation
Reference potency corticosteroid (1mg hydrocortisone = reference 1; prednisolone = 4; dexamethasone = 25)
Topical — mild eczema/dermatitis
0.5–2.5% cream or ointment twice daily (BD) to four times daily (QID)
Apply sparingly; use for shortest period; maximum 2 weeks continuously on face
Weakest topical corticosteroid — suitable for face, flexures, and children
Pediatric Dosing
CAH: 10–15mg/m²/day in 3 doses; Adrenal crisis in neonates: 25mg IV stat; Sick day rules: double/triple dose orally or IM injection kit for emergencies; do not use potent topical steroids (class III/IV) on children's face
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl <30 mL/min | No dose adjustment for replacement therapy; monitor for fluid retention; electrolyte imbalance may be exaggerated (mineralocorticoid effect) |
Hepatic Adjustment
Significant first-pass metabolism in liver; severe hepatic impairment may increase systemic exposure; use minimum effective dose
Pregnancy & Lactation
Pregnancy: Category C
Hydrocortisone is inactivated by placental 11β-HSD2 — less fetal exposure than dexamethasone/betamethasone. Drug of choice for replacement therapy in pregnant women with adrenal insufficiency. Sick day rules must continue during labour.
Lactation: Caution
Excreted in breast milk. Physiological replacement doses (15–25mg/day) considered acceptable during breastfeeding. Higher anti-inflammatory doses: monitor infant for adrenal suppression.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Rifampicin | Strong CYP3A4 inducer; reduces hydrocortisone levels by ~60%; patients on replacement therapy may develop adrenal crisis; double replacement dose during rifampicin course | Major |
| NSAIDs | Additive GI mucosal damage; increased risk of peptic ulceration and GI bleeding | Major |
| Antidiabetics (insulin, oral agents) | Hydrocortisone causes hyperglycemia (less than equivalent systemic doses of synthetic glucocorticoids due to shorter duration); dose adjustment of antidiabetics may be needed | Moderate |
| Loop diuretics (furosemide) / Thiazides | Additive hypokalemia due to mineralocorticoid activity of hydrocortisone; monitor potassium; supplement if needed | Moderate |
| Digoxin | Hypokalemia from mineralocorticoid effect enhances digoxin toxicity; monitor electrolytes and digoxin levels | Moderate |
| Phenytoin / Carbamazepine | CYP3A4 inducers reduce hydrocortisone levels; adrenal insufficient patients may need higher replacement doses | Moderate |
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Side Effects
Common
- Fluid retention and ankle oedema (mineralocorticoid effect)
- Hypertension
- Hyperglycemia
- Skin thinning, bruising, striae (topical and systemic)
- Weight gain
- Insomnia
- Mood changes
- Increased appetite
Serious / Discontinue If
- Adrenal crisis on abrupt withdrawal or failure of sick day rules
- Severe electrolyte disturbance (hypokalemia, sodium retention)
- Osteoporosis (long-term systemic use)
- Skin atrophy, telangiectasia, perioral dermatitis (prolonged topical use)
- Topical steroid withdrawal syndrome (prolonged use on face)
- Peptic ulceration and GI bleeding
- Cataract and glaucoma (prolonged use)
- Serious opportunistic infections
Contraindications
- Systemic fungal infections
- Live vaccine administration during immunosuppressive doses
- Hypersensitivity to hydrocortisone or any excipient
- Topical: rosacea, perioral dermatitis, acne vulgaris, untreated skin infections
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Solucortef 100mg injection | Pfizer | ₹185/vial |
| Efcorlin 100mg injection | Pfizer | ₹165/vial |
| Hydrocort 1% cream | Various (Abbott, Cipla) | ₹85/15g |
Monitoring Required
- Blood pressure and weight (mineralocorticoid effect monitoring)
- Serum electrolytes — sodium, potassium
- Blood glucose
- Morning cortisol levels (to assess adequacy of replacement — aim 400–600 nmol/L at 8–9 AM)
- Bone mineral density (DEXA) with long-term use
- Growth velocity in children with CAH
- Intraocular pressure (long-term use)
- Skin examination for atrophy (topical use)
Patient Counseling Points
- If you have Addison's disease or CAH: NEVER miss a dose — your body cannot make cortisol without this medicine. Carry a steroid card and medical alert bracelet at all times.
- Sick day rules: Double or triple your hydrocortisone dose when you are unwell (fever, vomiting, diarrhoea, surgery). If you cannot swallow, you need a hydrocortisone injection — keep an emergency injection kit at home.
- Go to the emergency department immediately if you cannot keep tablets down and show your steroid emergency card.
- Take the morning dose as soon as you wake up, and the afternoon dose by 3 PM — taking it later disrupts sleep.
- Topical hydrocortisone (cream): apply a thin layer only. Do not use for more than 2 weeks on the face. Do not cover with an occlusive dressing unless told to do so.
- Topical use around the eyes can cause glaucoma — inform your ophthalmologist if using near eyes.
- Do not use topical hydrocortisone on infected skin without specific advice — it can worsen infections.
- Inform all doctors, dentists, and paramedics that you take hydrocortisone before any procedure.
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Clinically reviewed by: Dr. Kavitha Nair, MD (Medicine), DM (Endocrinology), Amrita Institute of Medical Sciences, Kochi
Last reviewed: 2026-03-25
References
- Bornstein SR et al. Diagnosis and Treatment of Primary Adrenal Insufficiency (Addison's disease). J Clin Endocrinol Metab 2016;101(2):364–389.
- NICE Guideline NG243 (2023). Adrenal insufficiency: identification and management.
- Speiser PW et al. Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2018;103(11):4043–4088.
- BNF 86 (2024). Hydrocortisone monograph.
- CIMS India Drug Reference 2024. Hydrocortisone monograph.
- Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002;287(2):236–240.