HYDROCORTISONE

HYDROCORTISONE (hye-droe-kor'ti-sone) Aeroseb-HC, Cetacort, Cortaid, Cortenema, Dermolate, Hytone, Rectocort , Synacort HYDROCORTISONE ACETATE Anusol HC, Carmol HC, Cortaid, Cort-Dome, Corticaine, Cortifoam, Cortiment , Epifoam HYDROCORTISONE CYPIONATE Cortef HYDROCORTISONE SODIUM SUCCINATE A-Hydrocort, Solu-Cortef HYDROCORTISONE VALERATE Westcort Hydrocortisone Butyrate Locoid Classifications: antiinflammatory; synthetic hormone; adrenal corticosteroids; glucocorticoid; mineralocorticoid; Therapeutic: adrenal corticosteroid; antiinflammatory; immunosuppressant Pregnancy Category: C

Availability

Hydrocortisone: 5 mg, 10 mg, 20 mg tablets; 0.5%, 1%, 2.5% cream, lotion, ointment, spray

Hydrocortisone Acetate: 25 mg/mL, 50 mg/mL suspension; 0.5%, 1% cream, ointment

Hydrocortisone Cypionate: 5 mg, 20 mg tablet

Hydrocortisone Sodium Succinate: 100 mg/2 mL, 250 mg/2 mL, 500 mg/4 mL, 1000 mg/8 mL vials

Hydrocortisone Valerate: 0.2% cream, ointment

Hydrocortisone Butyrate: 0.1% cream, ointment, topical solution

Action

Short-acting synthetic steroid with both glucocorticoid and mineralocorticoid properties that affect nearly all systems of the body. Antiinflammatory (glucocorticoid) action: Stabilizes leukocyte lysosomal membranes; inhibits phagocytosis and release of allergic substances; suppresses fibroblast formation and collagen deposition; reduces capillary dilation and permeability; and increases responsiveness of cardiovascular system to circulating catecholamines. Immunosuppressive action: Modifies immune response to various stimuli; reduces antibody titers; and suppresses cell-mediated hypersensitivity reactions. Mineralocorticoid action: Promotes sodium retention, but under certain circumstances (e.g., sodium loading), enhances sodium excretion; promotes potassium excretion; and increases glomerular filtration rate (GFR). Metabolic action: Promotes hepatic gluconeogenesis, protein catabolism, redistribution of body fat, and lipolysis.

Therapeutic Effect

Has antiinflammatory, immunosuppressive, and metabolic functions in the body.

Uses

Replacement therapy in adrenocortical insufficiency; to reduce serum calcium in hypercalcemia, to suppress undesirable inflammatory or immune responses, to produce temporary remission in nonadrenal disease, and to block ACTH production in diagnostic tests. Use as antiinflammatory or immunosuppressive agent largely replaced by synthetic glucocorticoids that have minimal mineralocorticoid activity. Topically for atopic dermatitis or inflammatory conditions.

Contraindications

Hypersensitivity to glucocorticoids, idiopathic thrombocytopenic purpura, psychoses, acute glomerulonephritis, viral or bacterial diseases of skin, infections not controlled by antibiotics, active or latent amebiasis, hypercorticism (Cushing's syndrome), smallpox vaccination or other immunologic procedures; acne. Topical steroids contraindicated in presence of varicella, vaccinia, on surfaces with compromised circulation, and in children <2 y; pregnancy (category C).

Cautious Use

Children; diabetes mellitus; chronic, active hepatitis positive for hepatitis B surface antigen; hyperlipidemia; cirrhosis; stromal herpes simplex; glaucoma, tuberculosis of eye; osteoporosis; convulsive disorders; hypothyroidism; diverticulitis; nonspecific ulcerative colitis; fresh intestinal anastomoses; active or latent peptic ulcer; gastritis; esophagitis; thromboembolic disorders; CHF; metastatic carcinoma; hypertension; renal insufficiency; history of allergies; active or arrested tuberculosis; systemic fungal infection; myasthenia gravis; lactation.

Route & Dosage

Adrenal Insufficiency, Antiinflammatory Adult: PO 10–320 mg/d in 3–4 divided doses IV/IM 15–800 mg/d in 3–4 divided doses (max: 2 g/d) SC Sodium phosphate only, 15–240 mg/d Child: PO 2.5–10 mg/kg/d in 3–4 divided doses IV/IM 1–5 mg/kg/d divided q12–24h Intraarticular, Intralesional (Acetate Salt) Adult: IM 5–50 mg q3–5d for bursae; 5–50 mg once q1–4wk for joints Antiinflammatory Agent Adult: Topical Apply a small amount to the affected area 1–4 times/d PR Insert 1% cream, 10% foam, 10–25 mg suppository, or 100 mg enema nightly Atopic Dermatitis Adult/Adolescent/Child/Infant (>3 mo): Topical Apply sparingly b.i.d.

Administration

Note: Hydrocortisone phosphate may be given SC, IM, or IV. Hydrocortisone succinate may be given IM or IV.

Oral

• Give oral drug with food.

Rectal

• Administer retention enema preferably after a bowel movement; retain at least 1 h or all night if possible.

Topical

• Apply medication sparingly, rub until it disappears, and then reapply, leaving a thin coat over lesion. Completely cover area with transparent plastic or other occlusive device or vehicle when so ordered.
• Avoid covering a weeping or exudative lesion.
• Note: Occlusive dressings usually are not applied to face, scalp, scrotum, axilla, and groin.
• Inspect skin carefully between applications for ecchymotic, petechial, and purpuric signs, maceration, secondary infection, skin atrophy, striae or miliaria; if present, stop medication and notify physician.
• Store medication at 15°–30° C (59°–86° F) unless otherwise directed by manufacturer; protect from light and freezing.

Intramuscular

• Inject deep into gluteal muscle.

Intravenous IV administration to infants, children: Verify correct IV concentration and rate of infusion/injection with physician. PREPARE: Direct: Give undiluted (preferred) or diluted for infusion to 1 mg/mL or less than 100–1000 mL of D5W, NS, or D5/NS.  Intermittent: Dilute in 50–100 mL of D5W, NS, or D5/NS.   ADMINISTER: Direct: Give each dose at a rate of 500 mg or fraction thereof over 1 min.  Intermittent: Give over 10 min.   INCOMPATIBILITIES Solution/additive: Amobarbital, ampicillin, bleomycin, colistimethate, dimenhydrinate, doxapram, doxorubicin, ephedrine, heparin, hydralazine, metaraminol, methicillin, nafcillin, pentobarbital, phenobarbital, prochlorperazine, promethazine, secobarbital, tetracycline. Y-site: Ergotamine, phenytoin. Administer solutions that have been diluted for IV infusion within 24 h.

Adverse Effects (≥1%)

Body as a Whole: Hypersensitivity or anaphylactoid reactions; aggravation or masking of infections; malaise, weight gain, obesity; urogenital urinary frequency and urgency, enuresis increased or decreased motility and number of sperm. CNS: Vertigo, headache, nystagmus, ataxia (rare), increased intracranial pressure with papilledema (usually after discontinuation of medication), mental disturbances, aggravation of preexisting psychiatric conditions, insomnia, anxiety, mental confusion, depression. CV: Syncopal episodes, thrombophlebitis, thromboembolism or fat embolism, palpitation, tachycardia, necrotizing angiitis, CHF, hypertension edema. Endocrine: Suppressed linear growth in children, decreased glucose tolerance; hyperglycemia, manifestations of latent diabetes mellitus; hypocorticism; amenorrhea and other menstrual difficulties; moon facies. Special Senses: Posterior subcapsular cataracts (especially in children), glaucoma, exophthalmos, increased intraocular pressure with optic nerve damage, perforation of the globe, fungal infection of the cornea, decreased or blurred vision. Metabolic: Hypocalcemia; sodium and fluid retention; hypokalemia and hypokalemic alkalosis decreased serum concentration of vitamins A and C; hyperglycemia, hypernatremia. GI: Cramping, bleeding, nausea, increased appetite, ulcerative esophagitis, pancreatitis, abdominal distention, peptic ulcer with perforation and hemorrhage, melena. Hematologic: Thrombocytopenia, polycythemia, ecchymoses. Musculoskeletal: Osteoporosis, compression fractures, muscle wasting and weakness, tendon rupture, aseptic necrosis of femoral and humeral heads. Skin: Skin thinning and atrophy, acne, impaired wound healing; petechiae, ecchymosis, easy bruising; suppression of skin test reaction; hypopigmentation or hyperpigmentation, hirsutism, acneiform eruptions, subcutaneous fat atrophy; allergic dermatitis, urticaria, angioneurotic edema, increased sweating. With parenteral therapy at IV site–pain, irritation, necrosis, atrophy, sterile abscess; Charcot-like arthropathy following intraarticular use; burning and tingling in perineal area (after IV injection).

Diagnostic Test Interference

Hydrocortisone (corticosteroids) may increase serum cholesterol, blood glucose, serum sodium, uric acid (in acute leukemia) and calcium (in bone metastasis). It may decrease serum calcium, potassium, PBI, thyroxin (T₄), triiodothyronine (T₃) and reduce thyroid I 131 uptake. It increases urine glucose level and calcium excretion; decreases urine 17-OHCS and 17-KS levels. May produce false-negative results with nitroblue tetrazolium test for systemic bacterial infection and may suppress reactions to skin tests.

Interactions

Drug: barbiturates, phenytoin, rifampin may increase hepatic metabolism, thus decreasing cortisone levels; estrogens potentiate the effects of hydrocortisone; nsaids compound ulcerogenic effects; cholestyramine, colestipol decrease hydrocortisone absorption; diuretics, amphotericin B exacerbate hypokalemia; anticholinesterase agents (e.g., neostigmine) may produce severe weakness; immune response to vaccines and toxoids may be decreased.

Pharmacokinetics

Absorption: Readily from GI tract and IM injection site. Onset: 1–2 h PO; immediately IV; 3–5 d PR. Peak: 1 h PO; 4–8 h IM. Duration: 1–1.5 d PO/IM; 0.5–4 wk intraarticular. Distribution: Distributed primarily to muscles, liver, skin, intestines, kidneys; crosses placenta. Metabolism: In liver. Elimination: HPA suppression 8–12 h; metabolites excreted in urine; excreted in breast milk. Half-Life: 1.5–2 h.

Nursing Implications

Assessment & Drug Effects

• Establish baseline and continuing data on BP, weight, fluid and electrolyte balance, and blood glucose.
• Lab tests: Periodic serum electrolytes blood glucose, Hct and Hgb, platelet count, and WBC with differential.
• Monitor for adverse effects. Older adults and patients with low serum albumin are especially susceptible to adverse effects.
• Be alert to signs of hypocalcemia (see Appendix F).
• Ophthalmoscopic examinations are recommended every 2–3 mo, especially if patient is receiving ophthalmic steroid therapy.
• Monitor for persistent backache or chest pain; compression and spontaneous fractures of long bones and vertebrae present hazards.
• Monitor for and report changes in mood and behavior, emotional instability, or psychomotor activity, especially with long-term therapy.
• Be alert to possibility of masked infection and delayed healing (antiinflammatory and immunosuppressive actions).
• Note: Dose adjustment may be required if patient is subjected to severe stress (serious infection, surgery, or injury).
• Note: Single doses of corticosteroids or use for a short period (<1 wk) do not produce withdrawal symptoms when discontinued, even with moderately large doses.

Patient & Family Education

• Expect a slight weight gain with improved appetite. After dosage is stabilized, notify physician of a sudden slow but steady weight increase [2 kg (5 lb)/wk].
• Avoid alcohol and caffeine; may contribute to steroid-ulcer development in long-term therapy.
• Do not ignore dyspepsia with hyperacidity. Report symptoms to physician and do NOT self-medicate to find relief.
• Do NOT use aspirin or other OTC drugs unless prescribed specifically by the physician.
• Note: A high protein, calcium, and vitamin D diet is advisable to reduce risk of corticosteroid-induced osteoporosis.
• Notify physician of slow healing, any vague feeling of being sick, or return to pretreatment symptoms.
• Do not abruptly discontinue drug; doses are gradually reduced to prevent withdrawal symptoms.
• Report exacerbation of disease during drug withdrawal.
• Carry medical identification at all times. It needs to indicate medical diagnosis, drug therapy, and name of physician.
• Apply topical preparations sparingly in small children. The hazard of systemic toxicity is higher because of the greater ratio of skin surface area to body weight.
• Check shelf-life date on topical corticosterone during long-term use.

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Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug