Formulary
Hydrocortisone: Indications, Dosing, Side Effects and Interactions
Hydrocortisone has equal glucocorticoid and mineralocorticoid activity.
MedNext Academy | 18 min read
Hydrocortisone: Indications, Dosing, Side Effects and Interactions
Hydrocortisone has equal glucocorticoid and mineralocorticoid activity.
Drug action
Hydrocortisone has equal glucocorticoid and mineralocorticoid activity.
Indications and dose
**Thyrotoxic crisis [thyroid storm]**
- **Adult** (By Intravenous Injection): 100 mg every 6 hours, to be administered as sodium succinate.
**Adrenocortical insufficiency resulting from septic shock**
- **Adult** (By Intravenous Injection): 50 mg every 6 hours, to be given in combination with fludrocortisone.
**Acute hypersensitivity reactions such as angioedema of the upper respiratory tract and anaphylaxis [adjunct to adrenaline]**
- **Adult** (By Intravenous Injection): 100-300 mg, to be administered as sodium succinate.
**Corticosteroid replacement [patients who have taken more than 10 mg prednisolone per day or equivalent within 3 months of minor surgery under general anaesthesia]**
- **Adult** (By Intravenous Injection, Or By Intravenous Infusion): Initially 25-50 mg for 1 dose, to be administered at induction of surgery, the patient's usual oral corticosteroid dose is recommenced after surgery.
**Adrenocortical insufficiency in Addison's disease or following adrenalectomy**
- **Adult** (By Mouth Using Immediate-Release Medicines): 20-30 mg daily in 2 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, mimicking the normal diurnal rhythm of cortisol secretion, the optimum daily dose is determined on the basis of clinical response.
**Adrenal crisis in the community [in patients with adrenal insufficiency who are steroid-dependent]**
- **Child** (By Intramuscular Injection, Or By Intravenous Injection): 6-15 years 100 mg for 1 dose, patients should be admitted to hospital after the first dose, steroid treatment must not be stopped.
**Adrenal crisis in hospital when stable and improving [in patients with adrenal insufficiency who are steroid-dependent]**
- **Child** (By Intravenous Injection, Or By Intravenous Infusion): 1 month-15 years 1 mg/kg every 4-6 hours (max. per dose 50 mg).
**Adrenal crisis in hospital when stable and tolerating drinks and diet [in patients with adrenal insufficiency who are steroid-dependent]**
- **Child** (By Mouth): 1 month-15 years 7.5 mg/m 2 4 times a day, restart fludrocortisone if indicated.
**Severe inflammatory bowel disease**
- **Adult** (By Slow Intravenous Injection, Or By Intravenous Infusion): 100-500 mg 3-4 times a day or when required.
**Replacement in adrenocortical insufficiency**
- **Adult** (By Mouth Using Modified-Release Tablets): 20-30 mg once daily, dose to be taken in the morning, to be adjusted according to response.
- **Adult** (By Mouth Using Immediate-Release Medicines): 20-30 mg daily in 2 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, to be adjusted according to response.
**Congenital adrenal hyperplasia**
- **Adult** (By Mouth Using Modified-Release Capsules): 15-25 mg daily in 2 divided doses, take morning dose 1 hour before food and the evening dose at least 2 hours after last meal, at initiation, give two-thirds to three-quarters of the dose in the evening, and the remainder in the morning; adjust dose thereafter based on response. A lower dose may be sufficient in patients with remaining endogenous cortisol production.
**Acute hypersensitivity reactions,Angioedema**
- **Child** (By Intramuscular Injection, Or By Intravenous Injection): 12-17 years Initially 200 mg 3 times a day, dose to be adjusted according to response.
**Mild inflammatory skin disorders such as eczemas**
- **Child** (To The Skin): Apply 1-2 times a day, to be applied thinly.
- **Adult** (To The Skin): Apply 1-2 times a day, to be applied thinly.
**Nappy rash**
- **Child** (To The Skin): Apply 1-2 times a day for no longer than 1 week, to be discontinued as soon as the inflammation subsides.
**Severe acute asthma,Life-threatening acute asthma**
- **Child** (By Intravenous Injection): 12-17 years 4 mg/kg every 6 hours (max. per dose 100 mg) until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate, alternatively 100 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
- **Adult** (By Intravenous Injection): 100 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
**Local treatment of conjunctival inflammation [short-term]**
- **Adult** (To The Eye): Apply 2 drops 2-4 times a day for up to 14 days, to avoid relapse, frequency may be gradually reduced to once every other day.
**COVID-19 requiring supplemental oxygen [when dexamethasone cannot be used or is unavailable]**
- **Adult** (By Intravenous Injection, Or By Intravenous Infusion): 50 mg every 8 hours for 10 days, or until the day of discharge if this is sooner; may be continued for up to 28 days in patients with septic shock.
**Adrenal crisis [in patients with adrenal insufficiency who are steroid-dependent] for hydrocortisone**
- **Child 16-17 years** (Initially by intramuscular injection, or by intravenous injection): Initially 100 mg for 1 dose, then (by continuous intravenous infusion) 200 mg/24 hours, dilute in Glucose 5%, alternatively (by intramuscular injection or by intravenous injection) 50 mg every 6 hours, dose increased to 100 mg every 6 hours in patients who are severely obese.
**Adrenal crisis in the community [in patients with adrenal insufficiency who are steroid-dependent] for hydrocortisone**
- **Neonate** (By intramuscular injection, or by intravenous injection): 25 mg for 1 dose, patients should be admitted to hospital after the first dose, steroid treatment must not be stopped.
- **Child 1-11 months** (By intramuscular injection, or by intravenous injection): 25 mg for 1 dose, patients should be admitted to hospital after the first dose, steroid treatment must not be stopped.
- **Child 1-5 years** (By intramuscular injection, or by intravenous injection): 50 mg for 1 dose, patients should be admitted to hospital after the first dose, steroid treatment must not be stopped.
- **Child 6-15 years** (By intramuscular injection, or by intravenous injection): 100 mg for 1 dose, patients should be admitted to hospital after the first dose, steroid treatment must not be stopped.
**Adrenal crisis in hospital when illness is severe [in patients with adrenal insufficiency who are steroid-dependent] for hydrocortisone**
- **Neonate** (By intravenous injection, or by intravenous infusion): 4 mg/kg every 4-6 hours.
- **Child 1-11 months** (Initially by intramuscular injection, or by intravenous injection): Initially 25 mg for 1 dose, alternatively (by intravenous injection or by intravenous infusion) initially 2 mg/kg for 1 dose, then (by intravenous injection or by intravenous infusion) 2 mg/kg every 4-6 hours.
- **Child 1-5 years** (Initially by intramuscular injection, or by intravenous injection): Initially 50 mg for 1 dose, alternatively (by intravenous injection or by intravenous infusion) initially 2 mg/kg for 1 dose (max. per dose 100 mg), then (by intravenous injection or by intravenous infusion) 2 mg/kg every 4-6 hours (max. per dose 100 mg).
- **Child 6-15 years** (Initially by intramuscular injection, or by intravenous injection): Initially 100 mg for 1 dose, alternatively (by intravenous injection or by intravenous infusion) initially 2 mg/kg for 1 dose (max. per dose 100 mg), then (by intravenous injection or by intravenous infusion) 2 mg/kg every 4-6 hours (max. per dose 100 mg).
**Adrenal crisis in hospital when stable and improving [in patients with adrenal insufficiency who are steroid-dependent] for hydrocortisone**
- **Neonate** (By intravenous injection, or by intravenous infusion): 2 mg/kg every 4-6 hours.
- **Child 1 month-15 years** (By intravenous injection, or by intravenous infusion): 1 mg/kg every 4-6 hours (max. per dose 50 mg).
**Adrenal crisis in hospital when stable and tolerating drinks and diet [in patients with adrenal insufficiency who are steroid-dependent] for hydrocortisone**
- **Neonate** (By mouth): 7.5 mg/m2 4 times a day, restart fludrocortisone if indicated.
- **Child 1 month-15 years** (By mouth): 7.5 mg/m2 4 times a day, restart fludrocortisone if indicated.
**Congenital adrenal hyperplasia for hydrocortisone**
- **Neonate** (By mouth using immediate-release medicines): 9-15 mg/m2 daily in 3 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, to be adjusted according to response.
- **Child** (By mouth using immediate-release medicines): 9-15 mg/m2 daily in 3 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, to be adjusted according to response.
**Congenital adrenal hyperplasia [in patients who have not completed growth] for hydrocortisone**
- **Child 12-17 years** (By mouth using modified-release capsules): 10-15 mg/m2 daily in 2 divided doses, take morning dose 1 hour before food and the evening dose at least 2 hours after last meal, at initiation, give two-thirds to three-quarters of the dose in the evening, and the remainder in the morning; adjust dose thereafter based on response. A lower dose may be sufficient in patients with remaining endogenous cortisol production; maximum 25 mg per day.
**Congenital adrenal hyperplasia [in patients who have completed growth] for hydrocortisone**
- **Child 12-17 years** (By mouth using modified-release capsules): 15-25 mg daily in 2 divided doses, take morning dose 1 hour before food and the evening dose at least 2 hours after last meal, at initiation, give two-thirds to three-quarters of the dose in the evening, and the remainder in the morning; adjust dose thereafter based on response. A lower dose may be sufficient in patients with remaining endogenous cortisol production.
**Adrenal hypoplasia, Addison's disease, chronic maintenance or replacement therapy for hydrocortisone**
- **Neonate** (By mouth using immediate-release medicines): 8-10 mg/m2 daily in 3 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, higher doses may be needed.
- **Child** (By mouth using immediate-release medicines): 8-10 mg/m2 daily in 3 divided doses, a larger dose to be given in the morning and a smaller dose in the evening, higher doses may be needed.
**Inflammatory bowel disease-induction of remission for hydrocortisone**
- **Child 2-17 years** (By intravenous injection): 2.5 mg/kg every 6 hours (max. per dose 100 mg).
- **Child 2-17 years** (By continuous intravenous infusion): 10 mg/kg/24 hours (max. per dose 400 mg/24 hours).
**Acute hypersensitivity reactions, Angioedema for hydrocortisone**
- **Child 1-5 months** (By intramuscular injection, or by intravenous injection): Initially 25 mg 3 times a day, dose to be adjusted according to response.
- **Child 6 months-5 years** (By intramuscular injection, or by intravenous injection): Initially 50 mg 3 times a day, dose to be adjusted according to response.
- **Child 6-11 years** (By intramuscular injection, or by intravenous injection): Initially 100 mg 3 times a day, dose to be adjusted according to response.
- **Child 12-17 years** (By intramuscular injection, or by intravenous injection): Initially 200 mg 3 times a day, dose to be adjusted according to response.
**Hypotension resistant to inotropic treatment and volume replacement [limited evidence] for hydrocortisone**
- **Neonate** (By intravenous injection): Initially 2.5 mg/kg for 1 dose, then 2.5 mg/kg for 1 dose, to be given 4 hours after first dose if required, followed by 2.5 mg/kg every 6 hours for 48 hours or until blood pressure recovers, dose to then be reduced gradually over at least 48 hours.
- **Child** (By intravenous injection): 1 mg/kg every 6 hours (max. per dose 100 mg).
**Mild inflammatory skin disorders such as eczemas for hydrocortisone**
- **Child** (To the skin): Apply 1-2 times a day, to be applied thinly.
**Nappy rash for hydrocortisone**
- **Child** (To the skin): Apply 1-2 times a day for no longer than 1 week, to be discontinued as soon as the inflammation subsides.
**Severe acute asthma, Life-threatening acute asthma for hydrocortisone**
- **Child 1 month-1 year** (By intravenous injection): 4 mg/kg every 6 hours (max. per dose 100 mg) until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate, alternatively 25 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
- **Child 2-4 years** (By intravenous injection): 4 mg/kg every 6 hours (max. per dose 100 mg) until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate, alternatively 50 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
- **Child 5-11 years** (By intravenous injection): 4 mg/kg every 6 hours (max. per dose 100 mg) until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate, alternatively 100 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
- **Child 12-17 years** (By intravenous injection): 4 mg/kg every 6 hours (max. per dose 100 mg) until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate, alternatively 100 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate.
**Aphthous ulcers for hydrocortisone**
- **Child 1 month-11 years** (By oromucosal administration using buccal tablet): Only on medical advice.
- **Child 12-17 years** (By oromucosal administration using buccal tablet): 2.5 mg 4 times a day, allow buccal tablet to dissolve slowly in the mouth in contact with the ulcer.
Cautions
For all corticosteroids (systemic) Congestive heart failure; diabetes mellitus (including a family history of); diverticular disease (increased risk of diverticular perforation); diverticulitis; epilepsy; glaucoma (including a family history of or susceptibility to); history of steroid myopathy; history of tuberculosis or X-ray changes (frequent monitoring required); hypertension; hypothyroidism; infection (particularly untreated); long-term use; myasthenia gravis; ocular herpes simplex (risk of corneal perforation); osteoporosis (in children); osteoporosis (postmenopausal women and the elderly at risk) (in adults); peptic ulcer; psychiatric reactions; recent intestinal anastomoses; recent myocardial infarction (rupture reported); severe affective disorders (particularly if history of steroid-induced psychosis); thromboembolic disorders; ulcerative colitis Cautions, further information With intra-articular use or intradermal use or intralesional use: For further information on cautions associated with intra-articular, intradermal, and intralesional preparations, consult product literature. Elderly In adults: Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: if used instead of inhaled corticosteroids for maintenance therapy in moderate to severe COPD (unnecessary exposure to long-term side-effects) as long-term (longer than 3 months) monotherapy for rheumatoid arthritis (risk of side-effects) for treatment of osteoarthritis other than for periodic intra-articular injections for monoarticular pain (risk of side-effects) with concurrent NSAIDs without proton pump inhibitor prophylaxis (increased risk of peptic ulcer disease) Cautions For all corticosteroids (topical) Avoid prolonged use (particularly on the face); cautions applicable to systemic corticosteroids may also apply if absorption occurs following topical and local use; dermatoses of infancy, including nappy rash (extreme caution required-treatment should be limited to 5-7 days) (in children); infection; keep away from eyes; use potent or very potent topical corticosteroids under specialist supervision (in children); use potent or very potent topical corticosteroids under specialist supervision in psoriasis (can result in rebound relapse, development of generalised pustular psoriasis, and local and systemic toxicity) (in adults) Cautions For hydrocortisone When used by eye Concomitant use of ocular NSAIDs (in adults) Cautions, further information Concomitant use of ocular NSAIDs When used by eye in adults: Concomitant use of ocular formulations containing corticosteroids with ocular formulations containing NSAIDs may increase the risk of corneal healing problems, leading to corneal melt or scarring and loss of vision. M
Contraindications
For all corticosteroids (systemic) Avoid live virus vaccines in those receiving immunosuppressive doses (serum antibody response diminished); systemic infection (unless specific therapy given) Contra-indications, further information With intra-articular use or intradermal use or intralesional use: For further information on contra-indications associated with intra-articular, intradermal and intralesional preparations, consult product literature. Contra-indications For all corticosteroids (topical) Acne; perioral dermatitis; potent corticosteroids in widespread plaque psoriasis; rosacea; untreated bacterial, fungal or viral skin lesions Contra-indications For hydrocortisone With buccal use Untreated local infection
Side effects
For all corticosteroids (systemic) Common or very common Anxiety; appetite increased; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing's syndrome; electrolyte imbalance; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorder; vision blurred; weight increased Uncommon Adrenal suppression; alkalosis hypokalaemic; bone fractures; diabetic control impaired; glaucoma; haemorrhage; heart failure; hyperhidrosis; leucocytosis; myopathy; osteonecrosis; pancreatitis; papilloedema; seizure; thromboembolism; tuberculosis reactivation; vertigo Rare or very rare Tendon rupture Frequency not known Chorioretinopathy; eye disorders; growth retardation (very common in children); intracranial pressure increased with papilloedema (usually after withdrawal) Side-effects, further information Adrenal suppression During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy develops and can persist for years after stopping. Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension, or death. To compensate for a diminished adrenocortical response caused by prolonged corticosteroid treatment, any significant intercurrent illness, trauma, or surgical procedure requires a temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment. For vamorolone, there is no evidence on the effects of increasing the dose, and temporary supplementation with hydrocortisone is advised. Infections Prolonged courses of corticosteroids increase susceptibility to infections and severity of infections; clinical presentation of infections may also be atypical. Serious infections e.g. septicaemia and tuberculosis may reach an advanced stage before being recognised, and amoebiasis or strongyloidiasis may be activated or exacerbated (exclude before initiating a corticosteroid in those at risk or with suggestive symptoms). Fungal or viral ocular infections may also be exacerbated. Chickenpox Unless they have had chickenpox, patients receiving oral or parenteral corticosteroids for purposes other than replacement should be regarded as being at risk of severe chickenpox. Manifestations of fulminant illness include pneumonia, hepatitis and disseminated intravascular coagulation; rash is not necessarily a prominent feature. Passive immunisation with varicella-zoster immunoglobulin is needed for exposed non-immune patients receiving systemic corticosteroids or for those who have used them within the previous 3 months. Confirmed chickenpox warrants specialist care and urgent treatment. Corticosteroids should not be stopped and dosage may need to be increased. Measles Patients taking corticosteroids should be advised to take particular care to avoid exposure to measles and to seek immediate medical advice if exposure occurs. Prophylaxis with intramuscular normal immunoglobulin may be needed. Psychiatric reactions Systemic corticosteroids, particularly in high doses, are linked to psychiatric reactions including euphoria, insomnia, irritability, mood lability, suicidal thoughts, psychotic reactions, and behavioural disturbances. These reactions frequently subside on reducing the dose or discontinuing the corticosteroid but they may also require specific management. Patients should be advised to seek medical advice if psychiatric symptoms (especially depression and suicidal thoughts) occur and they should also be alert to the rare possibility of such reactions during withdrawal of corticosteroid treatment. Systemic corticosteroids should be prescribed with care in those predisposed to psychiatric reactions, including those who have previously suffered corticosteroid-induced psychosis, or who have a personal or family history of psychiatric disorders. When used by eye (topical) Vision disorders can occur with use of topical (eye) corticosteroids. Consider seeking specialist advice to evaluate cause if vision blurred or other vision disorder occurs. Side-effects For all corticosteroids (topical) Common or very common Skin reactions; telangiectasia Rare or very rare Adrenal suppression; hypertrichosis; skin depigmentation (may be reversible) Frequency not known Local reaction; vasodilation Side-effects, further information Side-effects applicable to systemic corticosteroids may also apply if absorption occurs following topical and local use. In order to minimise the side-effects of a topical corticosteroid, it is important to apply it thinly to affected areas only, no more frequently than twice daily, and to use the least potent formulation which is fully effective. Side-effects For hydrocortisone Frequency not known When used by eye (topical) Eye stinging With intra-articular use Malaise; myocardial rupture (following recent myocardial infarction) With oral use Dyslipidaemia; fatigue; hypotension; malaise; myocardial rupture (following recent myocardial infarction); oedema With parenteral use Hiccups; Kaposi's sarcoma; lipomatosis; malaise; myocardial rupture (following recent myocardial infarction)
Interactions
**Other interactions (2):**
- Corticosteroids or ACTH may intensify any thiazide-induced electrolyte depletion, particularly hypokalaemia mainly with the naturally occurring corticosteroids such as cortisone and hydrocortisone.
- Decrease of antihypertensive effect Nicardipine in combination with intravenous corticosteroids (glucocorticoids and mineralocorticoids) and tetracosactide (except for hydrocortisone used as...
Pregnancy
For all corticosteroids (systemic) The benefit of treatment with corticosteroids during pregnancy outweighs the risk. Corticosteroid cover is required during labour. Following a review of the data on the safety of systemic corticosteroids used in pregnancy and breast-feeding the CSM (May 1998) concluded that corticosteroids vary in their ability to cross the placenta but there is no convincing evidence that systemic corticosteroids increase the incidence of congenital abnormalities such as cleft palate or lip. When administration is prolonged or repeated during pregnancy, systemic corticosteroids increase the risk of intra-uterine growth restriction; there is no evidence of intra-uterine growth restriction following short-term treatment (e.g. prophylactic treatment for neonatal respiratory distress syndrome). Any adrenal suppression in the neonate following prenatal exposure usually resolves spontaneously after birth and is rarely clinically important. Monitoring in pregnancy Pregnant women with pre-eclampsia or fluid retention should be monitored closely when given systemic corticosteroids.
Breast feeding
For all corticosteroids (systemic) The benefit of treatment with corticosteroids during breast-feeding outweighs the risk.
Hepatic impairment
For all corticosteroids (systemic) In general, manufacturers advise caution (risk of increased exposure).
Renal impairment
For all corticosteroids (systemic) In general, manufacturers advise caution.
Medicinal forms
Capsule,Tablet,Tablet,Tablet,Capsule,Solution,Granules,Solution,Solution,Solution,Drops,Cream,Ointment
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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