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Sunday, July 27, 2025

Hydrocortisone injections


Hydrocortisone injections are sterile corticosteroid formulations used for systemic or local administration to control inflammatory, autoimmune, and allergic disorders, and to replace cortisol in adrenal insufficiency. These injections provide rapid and potent glucocorticoid effects and are critical in emergency scenarios like adrenal crisis, anaphylaxis adjunctive care, and severe asthma exacerbations. The most common injectable form is hydrocortisone sodium succinate, which is water-soluble and suitable for intravenous or intramuscular use.

Pharmacological Classification

  • Class: Systemic corticosteroid (glucocorticoid)

  • Formulations:

    • Hydrocortisone sodium succinate (e.g., Solu-Cortef) – water-soluble

    • Hydrocortisone acetate – for intra-articular or intramuscular use only

  • ATC Code: H02AB09

Mechanism of Action

Hydrocortisone injections act by binding to intracellular glucocorticoid receptors, influencing the transcription of anti-inflammatory and immunomodulatory genes, and suppressing pro-inflammatory cytokines such as IL-1, TNF-α, and prostaglandins. Systemic effects include:

  • Inhibition of leukocyte infiltration at the site of inflammation

  • Suppression of immune responses

  • Reduction in edema and capillary permeability

  • Stabilization of cell membranes

  • Support of vascular responsiveness to catecholamines (especially important in adrenal crisis)

Therapeutic Indications

Emergency and Replacement Therapy

  • Adrenal insufficiency (Addisonian crisis)

  • Congenital adrenal hyperplasia (acute stress)

  • Septic shock (adjunctive in adrenal insufficiency)

  • Preoperative or perioperative steroid cover in known adrenal suppression

Inflammatory and Autoimmune Disorders

  • Severe asthma exacerbation or status asthmaticus

  • Anaphylaxis (adjunct to epinephrine)

  • Acute allergic reactions

  • Rheumatoid arthritis

  • Systemic lupus erythematosus

  • Vasculitis syndromes

  • Giant cell arteritis

  • Autoimmune hemolytic anemia

  • Acute exacerbations of multiple sclerosis

Infectious and Neoplastic

  • Meningitis (as adjunctive therapy)

  • Cerebral edema associated with malignancy

  • Leukemia/lymphoma (as part of chemotherapy protocols)

Local Administration

  • Hydrocortisone acetate may be used for:

    • Intra-articular injections (e.g., rheumatoid arthritis, bursitis)

    • Intralesional injections (e.g., keloids)

Dosage and Administration

Hydrocortisone Sodium Succinate (IV/IM) – e.g., Solu-Cortef

Emergency (Adrenal Crisis)

  • Initial dose: 100 mg IV bolus

  • Followed by:

    • 200 mg over 24 hours (continuous IV or 50 mg every 6 hours)

    • Taper as patient stabilizes (typically to oral hydrocortisone)

Severe Allergy / Asthma

  • 100–500 mg IV or IM, depending on severity

  • May be repeated at 2-6 hour intervals

Maintenance Dose

  • 20–240 mg daily in divided doses (e.g., in rheumatic or autoimmune disorders)

Hydrocortisone Acetate (IM only)

  • 25–125 mg IM injection for inflammatory joint conditions

Paediatric Dosage

  • Stress dose: 1–2 mg/kg IV bolus, max 100 mg

  • Adjust maintenance based on body surface area or clinical status

Pharmacokinetics

  • Onset: Rapid (within 1 hour IV, slower IM)

  • Peak: 30–60 minutes (IV)

  • Half-life: ~1.5–2 hours (biologic effects last longer)

  • Metabolism: Hepatic (CYP3A4)

  • Excretion: Renal as inactive metabolites

Contraindications

  • Systemic fungal infections

  • Hypersensitivity to hydrocortisone or excipients

  • Intrathecal administration (contraindicated)

  • Live or attenuated vaccines during high-dose therapy

Warnings and Precautions

  • Do not stop abruptly after prolonged use due to risk of adrenal insufficiency

  • Monitor blood pressure, blood glucose, and electrolytes during high-dose therapy

  • Increased risk of infection, including latent TB reactivation

  • Risk of gastrointestinal bleeding or perforation, especially with NSAIDs

  • May cause psychological disturbances, especially with higher doses

  • Prolonged use may lead to osteoporosis, glaucoma, or Cushingoid features

  • Use cautiously in diabetes, hypertension, peptic ulcer, sepsis, and osteoporosis

Adverse Effects

Short-Term (High-Dose Therapy)

  • Hyperglycemia

  • Fluid retention, edema

  • Mood disturbances: euphoria, anxiety, insomnia

  • Hypertension

  • Electrolyte imbalance (hypokalemia)

  • Leukocytosis (due to demargination)

Long-Term Use

  • Cushing’s syndrome

  • Osteoporosis

  • Myopathy

  • Cataracts and glaucoma

  • Skin thinning, bruising

  • HPA axis suppression

  • Avascular necrosis (femoral head)

  • Growth suppression in children

Drug Interactions

  • CYP3A4 inducers (rifampin, phenytoin): reduce hydrocortisone levels

  • CYP3A4 inhibitors (ketoconazole, erythromycin): increase systemic exposure

  • NSAIDs: Additive risk of GI bleeding

  • Warfarin: May alter anticoagulant effects (monitor INR)

  • Vaccines: Reduced efficacy; avoid live vaccines during therapy

  • Diuretics: Additive hypokalemia

  • Insulin and oral hypoglycemics: Require dose adjustment due to hyperglycemic effects

Special Populations

Pregnancy

  • Category C; used when benefit outweighs risk

  • Short-term use for adrenal support in labor is standard

  • Monitor for fetal adrenal suppression with high or prolonged maternal dosing

Lactation

  • Present in breast milk; low doses are considered safe

  • Monitor infant for growth and adrenal function if used in high doses

Pediatric Use

  • Monitor for growth suppression and adrenal axis suppression

  • Use the lowest effective dose for the shortest duration

Elderly

  • Greater risk of osteoporosis, diabetes, and cardiovascular effects

Administration Notes

  • IV use: Reconstitute lyophilized powder with sterile water

  • IM use: For slower onset and longer duration

  • Do not mix with other drugs in the same syringe

  • Avoid repeated intra-articular injections due to joint damage risk

  • Use aseptic technique to reduce infection risk

  • Label as “steroid” in emergency charts and MedicAlert bracelet

Storage

  • Store vials at 15–25°C (room temperature)

  • Protect from light and excessive moisture

  • Use reconstituted solution immediately or within 24 hours if refrigerated

Brand Names

  • Solu-Cortef® (Pfizer): Hydrocortisone sodium succinate

  • Hydrocortistab®, Hydrocortone (Generic)

  • Efcortesol® (UK)

  • Cortef® (oral equivalent)



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