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Hydrocortisone Uses, Dosage, Side Effects & Warnings | DrugsAtlas

Authoritative Clinical Reference

Therapeutic Class

Corticosteroid

Subclass

Glucocorticoid (with significant mineralocorticoid activity)

Speciality

Endocrinology

Schedule (India)

Schedule H

Routes

Oral, Intravenous (IV), Intramuscular (IM), Topical, Rectal

Formulations

Form	Strengths Available
Tablets	5 mg, 10 mg, 20 mg
Injection (Hydrocortisone sodium succinate)	100 mg/vial, 250 mg/vial (lyophilized powder for reconstitution)
Topical cream/ointment	0.5%, 1%, 2.5%
Rectal preparations	Enema 100 mg/60 mL (limited availability); Suppositories (limited availability)

Adult indications

INDICATIONS + DOSING — FOR CLINICIAN USE ONLY

Primary Indications (Approved / Standard in India)

1. Primary Adrenal Insufficiency (Addison's Disease)

Parameter	Recommendation
Starting dose	15–20 mg/day orally in divided doses
Titration	Adjust based on clinical response, fatigue levels, electrolytes, and postural BP
Usual maintenance dose	15–25 mg/day in 2–3 divided doses (typically 10–15 mg morning, 5 mg afternoon ± 2.5–5 mg evening)
Maximum dose	30 mg/day (higher doses suggest over-replacement or stress dosing need)
Clinical notes	Morning dose should be largest to mimic physiological cortisol rhythm; most patients require concurrent fludrocortisone (50–200 mcg/day) for mineralocorticoid replacement

2. Secondary/Tertiary Adrenal Insufficiency

Parameter	Recommendation
Starting dose	10–15 mg/day orally in divided doses
Titration	Adjust based on clinical response
Usual maintenance dose	10–20 mg/day in 2–3 divided doses
Maximum dose	25 mg/day
Clinical notes	Fludrocortisone usually NOT required (aldosterone secretion preserved); lower doses often sufficient compared to primary AI

3. Acute Adrenal Crisis (Adrenal Emergency)

Parameter	Recommendation
Starting dose	100 mg IV bolus stat
Titration	Not applicable in acute phase
Usual maintenance dose	50–100 mg IV every 6–8 hours for first 24–48 hours, then taper based on clinical stability
Maximum dose	400 mg/day in first 24 hours
Clinical notes	Concurrent aggressive IV fluid resuscitation with 0.9% saline (1–2 L in first hour); identify and treat precipitant (infection, trauma, surgery); switch to oral when stable and tolerating feeds

Flow for Adrenal Crisis Management:

text

Suspected Adrenal Crisis

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IV access + Blood for cortisol (do NOT wait for results)

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Hydrocortisone 100 mg IV stat

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0.9% NaCl 1 L IV over 1 hour (then continue resuscitation)

↓

Hydrocortisone 50–100 mg IV every 6–8 hours

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Once stable (24–48 hrs): Halve IV dose daily → Convert to oral

↓

Resume maintenance oral dose + fludrocortisone (if primary AI)

4. Congenital Adrenal Hyperplasia (CAH) — Adult Maintenance

Parameter	Recommendation
Starting dose	15–25 mg/day orally in 2–3 divided doses
Titration	Guided by 17-hydroxyprogesterone, androstenedione, testosterone levels, and clinical signs
Usual maintenance dose	15–25 mg/day; reverse circadian dosing may be used (higher evening dose)
Maximum dose	30 mg/day
Clinical notes	Balance between adrenal suppression and avoiding Cushingoid features; often requires fludrocortisone; monitor for over-treatment (weight gain, striae, osteoporosis)

5. Septic Shock (Vasopressor-Refractory)

Parameter	Recommendation
Starting dose	200 mg/day IV
Titration	Not applicable
Usual maintenance dose	200 mg/day as continuous infusion OR 50 mg IV every 6 hours
Maximum dose	200 mg/day
Duration	Continue until vasopressors weaned; then taper over 2–3 days or stop abruptly if used <7 days
Clinical notes	Per Surviving Sepsis Campaign and ISCCM protocols; no ACTH stimulation test required before initiation; most benefit in patients requiring escalating vasopressors despite adequate fluid resuscitation

6. Severe Anaphylaxis (Adjunctive Therapy)

Parameter	Recommendation
Starting dose	200 mg IV stat
Titration	Not applicable
Usual maintenance dose	100 mg IV every 6–8 hours for 24–48 hours
Maximum dose	400 mg/day
Clinical notes	Always give AFTER adrenaline (first-line); role is to prevent biphasic reactions and late-phase inflammation; not a substitute for adrenaline; antihistamines given concurrently

7. Acute Severe Asthma (When Oral Not Possible)

Parameter	Recommendation
Starting dose	100 mg IV stat
Titration	Not applicable
Usual maintenance dose	100 mg IV every 6–8 hours
Maximum dose	400 mg/day
Duration	Until patient can tolerate oral steroids (usually 24–48 hours)
Clinical notes	Prednisolone 40–50 mg oral is preferred if patient can swallow; IV hydrocortisone reserved for severe cases with vomiting or impaired consciousness

8. Stress Dosing (Sick Day Rules / Perioperative)

Clinical Scenario	Hydrocortisone Dose
Minor illness (fever, gastroenteritis)	Double oral maintenance dose for 2–3 days
Unable to take oral medications	IM hydrocortisone 100 mg stat; seek medical care
Minor surgery (under local anaesthesia)	25–50 mg IV at induction
Moderate surgery	50–75 mg IV at induction, then 25–50 mg every 8 hours for 24–48 hours
Major surgery / Critical illness	100 mg IV at induction, then 50 mg every 6–8 hours for 48–72 hours; taper to maintenance

9. Inflammatory Skin Conditions (Topical Use)

Parameter	Recommendation
Starting dose	Apply thin layer to affected area 1–2 times daily
Titration	Step down to once daily or alternate days as inflammation controlled
Usual maintenance dose	Once daily or intermittent use
Maximum dose	Not applicable (limit duration; use sparingly on face/flexures)
Duration	1–2 weeks for most conditions; reassess if no improvement
Clinical notes	Low-potency topical steroid; suitable for face, flexures, children; avoid occlusive dressings on large areas

Secondary Indications — Adults (Off-label)

Indication	Dose	Duration	Evidence	Notes
Ulcerative colitis / Proctitis (distal)	Rectal enema 100 mg at bedtime OR foam preparation	2–4 weeks	Indian gastroenterology practice; API guidelines	OFF-LABEL; Specialist only; for left-sided/distal disease
Thyroid storm (adjunctive)	100 mg IV every 8 hours	Until crisis resolved	API Textbook; AIIMS protocols	OFF-LABEL; Blocks peripheral T4→T3 conversion; use with antithyroid drugs + beta-blockers
Relative adrenal insufficiency in critical illness	200 mg/day IV infusion	Duration of critical illness	ISCCM practice	OFF-LABEL; For patients on prolonged high-dose steroids prior to ICU
Multiple sclerosis relapse (alternative)	200–500 mg IV daily	3–5 days	Limited evidence; when methylprednisolone unavailable	OFF-LABEL; Specialist only; methylprednisolone preferred

Paediatric indications

PAEDIATRIC DOSING (Specialist Only)

⚠️ Age and Safety Statement

Paediatric dosing of hydrocortisone for adrenal conditions requires paediatric endocrinologist supervision
Growth velocity and bone age must be monitored regularly
Lowest effective dose should always be used to avoid growth suppression
Neonates and infants <3 months: Use only for life-threatening adrenal insufficiency under specialist supervision

Primary Paediatric Indications

1. Congenital Adrenal Hyperplasia (CAH)

Parameter	Infants & Young Children	Older Children/Adolescents
Starting dose	10–15 mg/m²/day in 3 divided doses	10–15 mg/m²/day in 3 divided doses
Titration	Adjust based on 17-OHP, androstenedione, growth velocity	Adjust based on hormonal control and growth
Usual maintenance dose	10–15 mg/m²/day divided TDS	10–15 mg/m²/day divided TDS
Maximum dose	20 mg/m²/day (higher suggests need for review)	25 mg/m²/day
Clinical notes	Divided TDS to mimic diurnal rhythm; highest dose in morning; fludrocortisone required in salt-wasting forms

Monitoring in CAH:

Growth velocity and height percentile every 3 months
Bone age annually
17-hydroxyprogesterone, androstenedione levels
Blood pressure (for fludrocortisone adjustment)
Signs of virilization or Cushingoid features

2. Primary Adrenal Insufficiency (Paediatric)

Parameter	Recommendation
Starting dose	8–10 mg/m²/day orally in 3 divided doses
Titration	Based on clinical response, energy levels, electrolytes
Usual maintenance dose	8–12 mg/m²/day in 2–3 divided doses
Maximum dose	15 mg/m²/day
Clinical notes	Physiological replacement; avoid over-treatment; fludrocortisone usually required

3. Acute Adrenal Crisis (Paediatric)

Age Group	IV Bolus Dose	Maintenance (24 hours)
Neonates / Infants <1 year	25 mg IV stat	25–30 mg/m²/day in divided doses
1–5 years	50 mg IV stat	50–100 mg/m²/day in divided doses
6–12 years	50–100 mg IV stat	50–100 mg/m²/day in divided doses
>12 years / Adolescents	100 mg IV stat	100 mg every 6–8 hours

Clinical notes: Concurrent IV 0.9% saline with dextrose; monitor glucose closely in infants; transition to oral maintenance once stable

4. Severe Acute Asthma (Paediatric)

Parameter	Recommendation
Starting dose	4 mg/kg IV stat (max 100 mg)
Titration	Not applicable
Usual maintenance dose	4 mg/kg IV every 6 hours (max 100 mg/dose)
Maximum dose	400 mg/day
Duration	Usually 24–48 hours IV, then switch to oral prednisolone
Clinical notes	Per IAP guidelines; oral prednisolone preferred if tolerated; IV for severe/life-threatening exacerbations

5. Stress Dosing (Paediatric — Sick Day Rules)

Situation	Dose
Minor febrile illness	Double or triple oral maintenance dose
Vomiting / Unable to take oral	IM hydrocortisone: Infants 25 mg, Children 50 mg, Adolescents 100 mg; seek immediate medical care
Minor procedures	25–50 mg IV at induction
Major surgery	50–100 mg/m² IV at induction, then 50–100 mg/m²/day in divided doses for 24–48 hours

Secondary Paediatric Indications (Off-label)

Indication	Dose	Duration	Notes
Ulcerative colitis (distal/rectal)	Rectal enema 25–50 mg at bedtime	2–4 weeks	OFF-LABEL; Paediatric GI specialist only
Severe croup (alternative to dexamethasone)	10 mg/kg IV (max 100 mg)	Single dose	OFF-LABEL; Dexamethasone preferred; use when dexamethasone unavailable

Renal Adjustments

Renal Function	Recommendation
eGFR ≥30 mL/min	No dose adjustment required
eGFR <30 mL/min	No dose adjustment; monitor fluid status and potassium
Haemodialysis	Not significantly dialysed; give after dialysis if timing relevant
Peritoneal dialysis	No adjustment; monitor for fluid retention

Clinical Note: Hydrocortisone has significant mineralocorticoid activity causing sodium and water retention; monitor for fluid overload and hypertension in patients with impaired renal function.

Hepatic adjustment

Contraindications

Known hypersensitivity to hydrocortisone or any excipients (including benzyl alcohol in some injectable preparations)
Systemic fungal infections (unless receiving concurrent appropriate antifungal therapy for life-threatening indication)
Cerebral malaria (corticosteroids worsen outcomes)
Administration of live attenuated vaccines during high-dose systemic corticosteroid therapy
Untreated active tuberculosis (unless on full anti-TB therapy)
Herpes simplex keratitis (topical ocular use)

Cautions

Diabetes mellitus (causes hyperglycaemia; may require antidiabetic dose adjustment)
Hypertension (sodium and fluid retention)
Congestive heart failure (fluid retention may worsen)
Peptic ulcer disease or history of GI bleeding
Osteoporosis or risk factors for bone loss
Glaucoma or family history of glaucoma
Psychiatric history (may precipitate or exacerbate mood disorders, psychosis)
Active or latent infections (may mask signs; reactivation risk)
Myasthenia gravis (initial worsening possible before improvement)
Hypothyroidism (reduced clearance)
Concurrent use of NSAIDs or anticoagulants
Recent intestinal anastomosis
Thromboembolic disorders

Pregnancy

Parameter	Details
Risk Category	Relatively safe; preferred corticosteroid in pregnancy when glucocorticoid required
Rationale	Extensively metabolised by placental 11β-hydroxysteroid dehydrogenase; minimal fetal exposure compared to dexamethasone/betamethasone
Preferred Alternatives	Prednisolone (also extensively metabolised by placenta)
When May Be Used	Adrenal insufficiency (essential); severe asthma; autoimmune flares requiring systemic steroids
Monitoring	Maternal: BP, blood glucose; Fetal: growth monitoring if prolonged use; Neonatal: observe for adrenal suppression if high maternal doses near delivery
Special Considerations	Use stress dosing during labour in women on chronic replacement therapy

Lactation

Parameter	Details
Compatibility	Compatible with breastfeeding at physiological replacement doses
Milk Levels	Low; minimal transfer into breast milk
Preferred Alternatives	Prednisolone (equally acceptable)
Infant Monitoring	Growth and weight gain if maternal dose >20 mg/day for prolonged periods; observe for signs of adrenal suppression (rare)
Recommendations	Physiological replacement doses safe; high-dose courses (>40 mg/day for >3 weeks) warrant monitoring infant

Elderly

Parameter	Recommendation
Recommended starting dose	Use lowest effective dose; start at lower end of dosing range
Titration	Slower titration; monitor closely for adverse effects
Extra risks	Osteoporosis and fractures (consider bone protection); Hyperglycaemia (may unmask or worsen diabetes); Hypertension and fluid retention (cardiac risk); Proximal myopathy; Skin fragility and poor wound healing; Cognitive effects (confusion, delirium); Increased infection susceptibility
Monitoring	More frequent BP, glucose, electrolyte monitoring; bone density if prolonged use anticipated

Major drug interactions

Interacting Drug	Effect	Mechanism	Recommendation
Rifampicin	Marked reduction in hydrocortisone efficacy	Strong CYP3A4 induction; accelerates cortisol metabolism	Increase hydrocortisone dose by 2–3 fold during rifampicin therapy; monitor for adrenal insufficiency
Phenytoin / Phenobarbital / Carbamazepine	Reduced hydrocortisone efficacy	CYP3A4 induction	May need to increase hydrocortisone dose; monitor clinical response
Ketoconazole / Itraconazole	Increased hydrocortisone levels and effects	CYP3A4 inhibition + direct adrenal enzyme inhibition	Monitor for Cushingoid features; consider dose reduction
Live vaccines (BCG, OPV, MMR, Varicella, Yellow Fever)	Risk of disseminated infection	Immunosuppression from steroids	AVOID during high-dose systemic therapy; defer vaccination until 3 months after stopping high-dose steroids
Warfarin	Unpredictable INR changes	Altered vitamin K-dependent factor synthesis	Monitor INR closely when starting, stopping, or changing hydrocortisone dose
Ritonavir	Increased hydrocortisone exposure	Strong CYP3A4 inhibition	Use with caution; monitor for steroid toxicity
Mifepristone	Antagonises glucocorticoid effects	Glucocorticoid receptor antagonist	Avoid concurrent use in adrenal insufficiency

Moderate drug interactions

Interacting Drug	Effect	Recommendation
NSAIDs	Increased risk of GI bleeding and ulceration	Use PPI prophylaxis if co-prescription necessary; avoid prolonged concurrent use
Thiazide / Loop diuretics	Enhanced hypokalaemia	Monitor potassium; supplement if needed
Digoxin	Hypokalaemia increases digoxin toxicity risk	Monitor potassium and digoxin levels
Oral antidiabetics / Insulin	Reduced glycaemic control	May need to increase antidiabetic doses; monitor blood glucose frequently
Methotrexate	Increased haematological toxicity risk	Monitor FBC more frequently
Fluoroquinolones	Increased risk of tendinopathy	Counsel about tendon symptoms; consider alternatives
Antihypertensives	Reduced antihypertensive efficacy	May need to uptitrate antihypertensive dose; monitor BP
Amphotericin B	Severe hypokalaemia	Monitor potassium closely; supplement aggressively
Salicylates (high-dose)	Increased salicylate clearance; toxicity on steroid withdrawal	Monitor salicylate levels if dose changed
Isoniazid	Reduced isoniazid efficacy (mild)	Usually clinically insignificant; no routine adjustment needed
Antacids	May reduce oral hydrocortisone absorption	Separate administration by 2 hours

Common Adverse effects

Fluid retention and peripheral oedema
Weight gain
Hyperglycaemia
Hypertension
Increased appetite
Mood changes (euphoria, irritability, anxiety)
Insomnia
Dyspepsia, gastric irritation
Hypokalaemia
Acne
Skin thinning, easy bruising
Impaired wound healing
Menstrual irregularities

Serious Adverse effects

Adverse Effect	Clinical Notes
Adrenal suppression	Occurs with supraphysiological doses >2–3 weeks; requires gradual tapering; may be life-threatening if steroids stopped abruptly
Osteoporosis and pathological fractures	Risk with chronic use; vertebral and hip fractures; consider bone protection
Avascular necrosis of femoral head	Suspect if hip/groin pain; MRI for diagnosis
Steroid-induced psychosis	Dose-related; may occur at any point; requires dose reduction or cessation
Opportunistic infections	Reactivation of TB, fungal infections, Strongyloides hyperinfection
Peptic ulcer with perforation/haemorrhage	Especially with concurrent NSAIDs
Posterior subcapsular cataracts	With prolonged use
Steroid-induced glaucoma	Monitor intraocular pressure in susceptible individuals
Growth suppression	In children; use minimum effective dose
Cushing's syndrome (iatrogenic)	Truncal obesity, moon face, striae, buffalo hump
Hyperglycaemia / New-onset diabetes	May require antidiabetic therapy
Severe hypokalaemia	Especially with concurrent diuretics; cardiac arrhythmia risk
Anaphylaxis	Rare; usually to excipients in injectable preparations; requires immediate discontinuation

Monitoring requirements

Timing	Parameters
Baseline	Weight, BP, fasting glucose, electrolytes (Na, K), bone density (DEXA) if long-term use planned; baseline ophthalmology if high-dose or prolonged use anticipated
Short-term use (<2 weeks)	Blood glucose (especially in diabetics); BP; clinical response
During initiation/dose change	Glucose monitoring (particularly first 48–72 hours in hospitalised patients); electrolytes; clinical signs of fluid overload
Long-term use (>3 months)	DEXA scan (baseline and every 1–2 years); annual ophthalmology review (cataracts, glaucoma); HbA1c or fasting glucose every 3–6 months; height velocity in children; BP at each visit
Adrenal function	ACTH stimulation test if prolonged supraphysiological doses and need to assess adrenal recovery before tapering
Infection surveillance	Mantoux/IGRA before starting if high-dose planned in TB-endemic areas; low threshold for investigating infections

Brands in India

Oral Preparations

Brand Name	Manufacturer	Strength
Hisone	Samarth Pharma	5 mg, 10 mg, 20 mg tablets
Cortef	Pfizer (limited availability)	5 mg, 10 mg, 20 mg tablets
Hydrocort	Various	10 mg, 20 mg tablets

Injectable Preparations

Brand Name	Manufacturer	Strength
Solu-Cortef	Pfizer	100 mg, 250 mg vials
Hydrocortisone Sodium Succinate	Various (Samarth, Cadila)	100 mg, 250 mg vials
Lycort	Lyca Pharma	100 mg vial
Efcorlin	GSK/Various	100 mg, 250 mg vials

Topical Preparations

Brand Name	Manufacturer	Strength
Cortisone (cream/ointment)	Various	1%
Hydro-C	Various	1% cream
Wycort	Wyeth (limited)	1% cream

Rectal Preparations

Limited availability in India; may require specialist sourcing or compounding

Price range (INR)

Formulation	Approximate Price	Notes
Tablets 10 mg (strip of 10)	₹40–80	Variable availability
Tablets 20 mg (strip of 10)	₹60–120
Injection 100 mg vial	₹50–120	Unidentified
Injection 250 mg vial	₹100–180
Topical cream 1% (15 g)	₹30–80

NLEM Status: Hydrocortisone injection is included in NLEM India 2022
DPCO: Price-controlled for certain formulations
Government supply: Available in public hospitals, especially injectables for emergency use

Clinical pearls

Physiological replacement: For adrenal insufficiency, 20 mg hydrocortisone ≈ 5 mg prednisolone ≈ 0.75 mg dexamethasone in glucocorticoid potency; hydrocortisone preferred for replacement due to mineralocorticoid activity and shorter half-life
Circadian dosing: In adrenal insufficiency and CAH, give largest dose in morning (mimics cortisol awakening response); typical split is 10-15 mg morning, 5 mg afternoon ± 2.5-5 mg evening
Sick day rules are critical: All patients on replacement therapy must carry emergency injection kit and steroid alert card/bracelet; double oral dose for fever; IM if vomiting
Tapering guidance: Systemic steroids used >2–3 weeks at supraphysiological doses require gradual tapering; abrupt cessation risks adrenal crisis
Septic shock timing: In vasopressor-refractory septic shock, initiate hydrocortisone 200 mg/day early; no benefit from ACTH stimulation testing before starting
Bone protection: For anticipated use >3 months at >7.5 mg prednisolone-equivalent/day, initiate calcium, vitamin D, and consider bisphosphonate (particularly in elderly and postmenopausal women)
Perioperative stress: Patients on chronic steroids need stress-dose cover; failure to provide this is a preventable cause of perioperative collapse

Version

RxIndia v1.0 — 27 Jan 2025

Reference

- CDSCO approved prescribing information
- Indian Pharmacopoeia 2022
- NLEM India 2022
- API Textbook of Medicine (11th Edition) — Adrenal Disorders chapter
- ICMR Guidelines on Endocrine Disorders
- IAP Guidelines — Paediatric Endocrinology
- Indian Society of Critical Care Medicine (ISCCM) Sepsis Guidelines
- AIIMS Treatment Protocols — Endocrinology and Critical Care
- Surviving Sepsis Campaign Guidelines (for septic shock dosing, adapted to Indian practice)
- Endocrine Society Clinical Practice Guidelines — Adrenal Insufficiency (supportive reference)
- Goodman & Gilman's The Pharmacological Basis of Therapeutics (14th Edition)
- Harrison's Principles of Internal Medicine (21st Edition)

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