hydrocortisone

hydrocortisone

(hye droe kor' ti zone)

hydrocortisone acetate

Dermatologic cream, ointment:

Cortaid with Aloe, Cortef Feminine Itch, Corticaine, Gynecort Female Creme, Lanacort-5, Lanacort-10, Maximum Strength Caldecort, Maximum Strength Cortaid

hydrocortisone butyrate

Dermatologic ointment and cream:

Locoid

hydrocortisone cypionate

Oral suspension:

Cortate (CAN), Cortef

hydrocortisone sodium phosphate

IV, IM, or subcutaneous injection:

Hydrocortone phosphate

hydrocortisone sodium succinate

IV, IM injection:

Solu-Cortef

hydrocortisone valerate

Dermatologic cream, ointment, lotion:

Westcort

Pregnancy Category C

Drug classes

Corticosteroid, short acting

Glucocorticoid

Adrenal cortical steroid

Hormone

Therapeutic actions

Enters target cells and binds to cytoplasmic receptors; initiates many complex reactions that are responsible for its anti-inflammatory, immunosuppressive (glucocorticoid), and salt-retaining (mineralocorticoid) actions. Some actions may be undesirable, depending on drug use.

Indications

·        Replacement therapy in adrenal cortical insufficiency

·        Allergic states—severe or incapacitating allergic conditions

·        Hypercalcemia associated with cancer

·        Short-term inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (SLE), dermatologic diseases (pemphigus), status asthmaticus, and autoimmune disorders

·        Hematologic disorders—thrombocytopenic purpura, erythroblastopenia

·        Trichinosis with neurologic or myocardial involvement

·        Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas

·        Intra-articular or soft-tissue administration: Arthritis, psoriatic plaques

·        Retention enema: For ulcerative colitis, proctitis

·        Dermatologic preparations: To relieve inflammatory and pruritic manifestations of dermatoses that are steroid responsive

·        Anorectal cream, suppositories: To relieve discomfort of hemorrhoids and perianal itching or irritation

Contraindications and cautions

Systemic administration

·        Contraindicated with fungal infections, amebiasis, hepatitis B, vaccinia, or varicella, and antibiotic-resistant infections.

·        Use cautiously with kidney disease (risk to edema); liver disease, cirrhosis, hypothyroidism; ulcerative colitis with impending perforation; diverticulitis; recent GI surgery; active or latent peptic ulcer; inflammatory bowel disease (risks exacerbations or bowel perforation); hypertension, CHF; thromboembolitictendencies, thrombophlebitis, osteoporosis, seizure disorders, metastatic carcinoma, diabetes mellitus; TB; lactation.

Retention enemas, intrarectal foam

·        Contraindicated with systemic fungal infections, recent intestinal surgery, extensive fistulas.

·        Use cautiously with pregnancy.

Topical dermatologic administration

·        Contraindicated with fungal, tubercular, herpes simplex skin infections; vaccinia, varicella; ear application when eardrum is perforated.

·        Use cautiously with pregnancy, lactation.

Available forms

Tablets—5, 10, 20 mg; oral suspension—10 mg/5 mL, 25, 50 mg/mL; injection—25, 50 mg/mL, 100, 250, 500, 1,000 mg/vial; topical lotion—0.25%, 0.5%, 1%, 2%, 2.5%; topical liquid—1%; topical oil—1%; topical solution—1%; topical spray—1%; cream—0.2%, 0.5%, 1%, 2.5%; ointment—0.5%, 1%, 2.5%; topical gel—1%, 2%

Dosages

ADULTS

Individualize dosage, based on severity and response. Give daily dose before 9 AM to minimize adrenal suppression. If long-term therapy is needed, alternate-day therapy should be considered. After long-term therapy, withdraw drug slowly to avoid adrenal insufficiency. For maintenance therapy, reduce initial dose in small increments at intervals until lowest clinically satisfactory dose is reached.

IM, IV (hydrocortisone sodium succinate)

100–500 mg initially and q 2–10 hr, based on condition and response.

·        Acute adrenal insufficiency (hydrocortisone sodium phosphate): 100 mg IV followed by 100 mg q 8 hr in IV fluids.

PEDIATRIC PATIENTS

Individualize dosage based on severity and response rather than on formulae that correct adult doses for age or weight. Carefully observe growth and development in infants and children on prolonged therapy.

Oral (hydrocortisone and cypionate)

20–240 mg/day in single or divided doses.

ADULTS AND PEDIATRIC PATIENTS

IV, IM or subcutaneous (hydrocortisone and hydrocortisone sodium phosphate)

20–240 mg/day usually in divided doses q 12 hr.

IM, IV (hydrocortisone sodium succinate)

Reduce dose, based on condition and response, but give no less than 25 mg/day.

·        Retention enema (hydrocortisone): 100 mg nightly for 21 days.

Intrarectal foam (hydrocortisone acetate)

1 applicator daily or bid for 2 wk and every second day thereafter.

Intra-articular, intralesional (hydrocortisone acetate)

5–25 mg, depending on joint or soft-tissue injection site.

Topical dermatologic preparations

Apply sparingly to affected area bid–qid.

Pharmacokinetics

Route	Onset	Peak	Duration
Oral	1–2 hr	1–2 hr	1–1.5 days
IM	Rapid	4–8 hr	1–1.5 days
IV	Immediate	Unknown	1–1.5 days
PR	Slow	3–5 days	4–6 days

Metabolism: Hepatic; T_1/2: 80–120 min

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

IV facts

Preparation: Give directly or dilute in normal saline or D₅W. Administer within 24 hr of diluting

Infusion: Inject slowly, directly or dilute, and infuse hydrocortisone phosphate at a rate of 25 mg/min; hydrocortisone sodium succinate at rate of each 500 mg over 30–60 sec.

Incompatibilities: Do not mix or inject at Y-site with amobarbital, ampicillin, bleomycin, dimenhydrinate, doxapram, doxorubicin, ephedrine, ergotamine, heparin,hydralazine, metaraminol, methicillin, nafcillin, pentobarbital, phenobarbital, phenytoin, prochloperazine, promethazine, secobarbital, tetracyclines.

Adverse effects

Systemic

·        CNS: Vertigo, headache, paresthesias, insomnia, seizures, psychosis

·        CV: Hypotension, shock, hypertension and CHF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias secondary to electrolyte disturbances

·        Dermatologic: Thin, fragile skin; petechiae; ecchymoses; purpura; striae; subcutaneous fat atrophy

·        EENT: Cataracts, glaucoma (long-term therapy), increased IOP

·        Endocrine: Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance and diabetes mellitus, cushingoid state (long-term therapy), HPA suppression systemic with therapy longer than 5 days

·        GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite and weight gain (long-term therapy)

·        Hematologic: Na⁺ and fluid retention, hypokalemia, hypocalcemia, increased blood sugar, increased serum cholesterol, decreased serum T₃ and T₄levels

·        Hypersensitivity: Anaphylactoid or hypersensitivity reactions

·        Musculoskeletal: Muscle weakness, steroid myopathy and loss of muscle mass, osteoporosis, spontaneous fractures (long-term therapy)

·        Other: Immunosuppression, aggravation or masking of infections, impaired wound healing

Adverse effects related to specific routes of administration

·        IM repository injections: Atrophy at injection site

·        Intra-articular: Osteonecrosis, tendon rupture, infection

·        Intralesional therapy, head and neck: Blindness (rare)

·        Intraspinal: Meningitis, adhesive arachnoiditis, conus medullaris syndrome

·        Intrathecal administration: Arachnoiditis

·        Retention enema: Local pain, burning; rectal bleeding; systemic absorption and adverse effects (see Systemic Adverse Effects)

·        Topical dermatologic ointments, creams, sprays: Local burning, irritation, acneiform lesions, striae, skin atrophy

Interactions

Drug-drug

·        Increased steroid blood levels with hormonal contraceptives, troleandomycin, ketoconazole, estrogen

·        Decreased steroid blood levels with phenytoin, phenobarbital, rifampin, cholestyramine

·        Decreased serum level of salicylates

·        Decreased effectiveness of anticholinesterases (ambenonium, edrophonium, neostigmine, pyridostigmine), ketoconazole, estrogen

Drug-lab test

·        False-negative nitroblue-tetrazolium test for bacterial infection (with systemic absorption)

·        Suppression of skin test reactions

·        May decrease serum potassium levels, T₃, and T₄ levels

Nursing considerations

Assessment

·        History: Infections; kidney disease; liver disease, hypothyroidism; ulcerative colitis with impending perforation; diverticulitis; recent GI surgery; active or latent peptic ulcer; inflammatory bowel disease; hypertension, CHF; thromboembolitic tendencies, thrombophlebitis, osteoporosis, seizure disorders, metastatic carcinoma, diabetes mellitus; lactation. Retention enemas, intrarectal foam: Systemic fungal infections; recent intestinal surgery, extensive fistulas. Topical dermatologic administration: Fungal, tubercular, herpes simplex skin infections; vaccinia, varicella; ear application when eardrum is perforated

·        Physical: Systemic administration: Weight, T; reflexes, affect, bilateral grip strength, ophthalmologic examination; BP, P, auscultation, peripheral perfusion, discoloration, pain or prominence of superficial vessels; R, adventitious sounds, chest x-ray; upper GI x-ray (history or symptoms of peptic ulcer), liver palpation; CBC, serum electrolytes, 2-hr postprandial blood glucose, urinalysis, thyroid function tests, serum cholesterol. Topical, dermatologic preparations: Affected area, integrity of skin

Interventions

Systemic administration

·        WARNING: Give daily before 9 AM to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression.

·        Space multiple doses evenly throughout the day.

·        Do not give IM injections if patient has thrombocytopenic purpura.

·        Rotate sites of IM repository injections to avoid local atrophy.

·        Use minimal doses for minimal duration to minimize adverse effects.

·        Taper doses when discontinuing high-dose or long-term therapy.

·        Arrange for increased dosage when patient is subject to unusual stress.

·        Ensure that adequate amount of Ca²⁺ is taken if prolonged administration of steroids.

·        Use alternate-day maintenance therapy with short-acting corticosteroids whenever possible.

·        WARNING: Do not give live virus vaccines with immunosuppressive doses of hydrocortisone.

·        Provide antacids between meals to help avoid peptic ulcer.

Topical dermatologic administration

·        Use caution with occlusive dressings; tight or plastic diapers over affected area can increase systemic absorption.

·        Avoid prolonged use, especially near eyes, in genital and rectal areas, on face, and in skin creases.

Teaching points

Systemic administration

·        Take this drug exactly as prescribed. Do not stop taking this drug without notifying your health care provider; slowly taper dosage to avoid problems.

·        Dosage reductions may create adrenal insufficiency. Report any fatigue, muscle and joint pains, anorexia, nausea, vomiting, diarrhea, weight loss, weakness, dizziness, or low blood sugar (if you monitor blood sugar).

·        Take with meals or snacks if GI upset occurs.

·        Take single daily or alternate-day doses before 9 AM; mark calendar or use other measures as reminder of treatment days.

·        Do not overuse joint after intra-articular injections, even if pain is gone.

·        Frequent follow-up visits to your health care provider are needed to monitor drug response and adjust dosage.

·        Wear a medical alert ID (long-term therapy) so that any emergency medical personnel will know that you are taking this drug.

·        You may experience these side effects: Increase in appetite, weight gain (some of gain may be fluid retention; monitor intake); heartburn, indigestion (eat frequent small meals; use of antacids may help); increased susceptibility to infection (avoid crowds during peak cold or flu seasons, and avoid anyone with a known infection); poor wound healing (if injured or wounded, consult health care provider); muscle weakness, fatigue (frequent rest periods may help).

·        Report unusual weight gain, swelling of lower extremities, muscle weakness, black or tarry stools, vomiting of blood, epigastric burning, puffing of face, menstrual irregularities, fever, prolonged sore throat, cold or other infection, worsening of symptoms.

Intra-articular, intralesional administration

·        Do not overuse the injected joint even if the pain is gone. Adhere to rules of proper rest and exercise.

Topical dermatologic administration

·        Apply sparingly, and rub in lightly

·        Avoid contacting your eye with the medication.

·        Report burning, irritation, or infection of the site, worsening of the condition.

·        Avoid prolonged use.

Anorectal preparations

·        Maintain normal bowel function with proper diet, adequate fluid intake, and regular exercise.

·        Use stool softeners or bulk laxatives if needed.

·        Notify your health care provider if symptoms do not improve in 7 days or if bleeding, protrusion, or seepage occurs.

Adverse effects in Italic are most common; those in Bold are life-threatening.