HYDROCORTISONE (HYDROCORTONE®)

Available as tablets containing Hydrocortisone 10 mg and 20 mg supplied under the trade name HydrocortoneÒ .
An injection containing Hydrocortisone 100 mg is also available but rarely used for maintenance (replacement) therapy described below.

How does it work?

Hydrocortisone is one of the steroid hormones produced by the adrenal gland (adrenal cortex) which plays a complex role in regulating body functions and without which survival would not be possible. Hydrocortisone Tablets are taken as a replacement for the natural hormone where this is deficient either because there is a primary failure (or insufficiency) of Hydrocortisone production by the adrenal cortex gland (Addison’s Disease) or adrenal failure (or insufficiency) results from a pituitary deficiency of ACTH (the hormone that stimulates production of Hydrocortisone by the adrenal gland). Replacement therapy is also required for people who have a congenital adrenal hyperplasia (a birth defect) or in cases where surgical removal of the gland (adrenalectomy) has been performed.

How do I take it?

High doses of Hydrocortisone administered by injection are required in the acute management of adrenal insufficiency in order to establish initial control. The following describes treatment once this has been achieved and refers to normal (maintenance) therapy.

In primary adrenal failure (or insufficiency) it is usual to attempt to mimic the normal secretion of Hydrocortisone by the adrenal cortex by giving a standard (physiological) dose twice a day in the morning and evening. The usual dose of 30 mg Hydrocortisone per day is split into 20 mg taken with breakfast and 10 mg taken with the evening meal.

Some patients feel better on hydrocortisone given three times per day i.e. 10mg with breakfast, 10mg with midday meal and 10mg with evening meal. In those with primary adrenal failure the hydrocortisone is given with fludrocortisone as this hormone is also deficient.

The above treatment strategy also applies in secondary adrenal failure (e.g. pituitary failure) but is not combined with fludrocortisone.

What side effects can be expected?

• It is very important that you always carry a Steroid Card with you in the event that you taken ill and are seen by another Doctor. Cards are available from Chemists and should be supplied with your prescription. They tell other Doctors all they need to known about your treatment that might have a bearing on other treatments you require, especially in an emergency. It is often necessary, for example, to supplement the hydrocortisone that you take with extra doses by injection if you suffer an acute illness or if you require any form of surgery.
• The following is a list of possible side effects some or all of which can occur to a greater or lesser extent in some patients. Most are controlled by careful adjustment of dosage and are generally preventable by monitoring from time to time.
• Indigestion or abdominal discomfort is a relatively common side effect and the reason why each dose of Hydrocortisone should be taken with food. Peptic ulcers are more likely to develop in people who require long term treatment with medicines of this kind so that your Doctor should be informed if severe symptoms occur. Further investigation may be necessary in such cases.
• Long term treatment with steroids may lead to "thinning" of the bones and development of a condition known as osteoporosis which is associated with an increased risk of bone fractures. This is less likely to occur when normal (physiological) doses or even lower doses are used as is the case in the endocrine replacement of missing hormones.
• Steroids produce other metabolic side effects (i.e. interfere with the chemical balance of the body). They alter salt and water and potassium and calcium balance and increase blood sugar levels (diabetes may be unmasked in susceptible individuals). There is often an increased appetite, weight gain and susceptibility to infection and poor healing of injuries or wounds. Once again this is mainly seen with high dosages of hydrocortisone but far less often on normal replacement doses.
• High doses of steroids can be associated with menstrual irregularities and even complete absence of monthly periods, another reason to maintain the lowest dose feasible.
• A condition resembling Cushing’s Syndrome (Cushingoid) results from high or excessive dosage. The symptoms include the appearance of a typical large, rounded or "moon" face, a reddish/ruddy complexion, obesity which may be noticed as swelling of the trunk, and the deposition of pads of fatty tissue behind the shoulder blades described as a "buffalo hump". The skin texture can become thin and stretched, there may be purple streaks across the abdomen (due to damage to very small surface blood vessels). It is stressed that the Cushingoid appearance can be prevented or controlled by careful dosage adjustment. This is why your specialist aims for the lowest dose of hydrocortisone which makes you feel well.
• Steroids (especially in high dosage) can have unpredictable effects on mood and behaviour. This may be a particular problem for those who suffer from mental illness. Steroids have been associated with euphoria (a feeling of wellbeing) but also depression and occasionally cause sleep disturbances. They may also raise the intracranial pressure (pressure within the brain) associated with the development of headache.
• Steroids also raise the pressure of fluid within the eye ball (intra-ocular pressure) predisposing to the related condition glaucoma. Cataracts are more likely to form in people treated with steroids and there may be thinning of the outer cover of the eye with increased risk of eye infections.

Other medicines or substances which might interfere with your treatment

Ideally, steroids used for replacement therapy mimic the natural release of Hydrocortisone from the adrenal gland and should not have any effect on other treatments. In practice, however, steroid medicines can interfere with treatments for high blood pressure and diabetes so requiring more careful control of these conditions.

When steroids are taken with anti-inflammatory pain killers such as BrufenÒ , Naproxen, Diclofenac/VoltarolÒ , etc. there is an increased likelihood of stomach problems such as indigestion and even peptic ulceration. If in doubt – seek advice from your Doctor.

Some medicines used in the treatment of epilepsy can increase the metabolism of steroids so reducing their effect in the body. The concurrent use of the oral contraceptive, on the other hand, can increase the action of steroids. Any problems are easily overcome, however, by careful dosage adjustment.

The amount of potassium in the blood can be reduced by combinations of steroid and other medicines which lower potassium levels (e.g. diuretics or water tablets). The level of potassium in the blood requires to me maintained within an accepted range so that corrective measures may be necessary.

Advice for illness

If you become ill then the body naturally would increase the output of steroid from the adrenals. Therefore if you are on replacement steroid it is essential to mimic the natural response by doubling your dose of steroid until the illness is over.

What illnesses require extra replacement steroid?

1. Flu
2. Severe head cold
3. Infection
4. Fevers
5. Surgery
6. Dental surgery
7. Severe accidents

If you have diarrhoea or vomiting then you might not absorb your steroid even if you have doubled the dose so best to seek advice urgently from your GP or call at A+E. Remember you MUST see a doctor that day when you have diarrhoea or vomiting.

What if a dose is missed by mistake?

One dose missed is unlikely to cause a problem but missing two dosages could land you in hospital. Try to remember.

Storing your medicine

Hydrocortisone tablets should be stored at room temperature. Avoid exposure to excessive heat or moisture.

Ó Tayside University Hospitals NHS Trust; 2000; version 1.0Disclaimer; no liability whatsoever is accepted for information given and all such information, especially with regard to drug usage (UK version provided), must be checked with a person’s health provider.