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Corticosteroid Pregnancy: Hydrocortisone readily crosses the placenta. Administration of corticosteroids to pregnant animals can cause abnormalities of foetal development including cleft palate, intra-uterine growth retardation and effects on brain growth and development. There is no evidence that corticosteroids increase the incidence of congenital abnormalities such as cleft palate in man, but when administered for long periods or repeatedly during pregnancy they may increase the risk of intra-uterine growth retardation; the risk of low birth weight appears dose related and may be minimised by using lower doses. Hypoadrenalism may in theory occur in the neonate following prenatal exposure, but usually resolves spontaneously after birth and is rarely clinically important. Cataracts have been observed in infants born to mothers treated with long-term corticosteroids during pregnancy. Corticosteroids should only be prescribed when the benefits to mother and child outweigh the risks; when they are essential, patients with normal pregnancies may be treated as though they were in the non-gravid state. Breast-feeding: corticosteroids are excreted in breast milk, although no data are available for hydrocortisone. Doses up to 160 mg daily are unlikely to cause systemic effects in the infant; infants of mothers taking higher doses may have a degree of adrenal suppression, but the benefits of breast-feeding are likely to outweigh any theoretical risk.

Hydrocortisone

Brand names: Solu-Cortef, Hydrocortistab

Used in: Anaphylaxis & Allergy

Hydrocortisone is a glucocorticoid (with mineralocorticoid activity) used parenterally in emergencies including adrenal crisis, severe asthma, anaphylaxis as an adjunct and acute severe inflammatory reactions.

Adult dose

Dose: Conditions requiring a rapid and intense corticosteroid effect — including primary or secondary adrenocortical insufficiency, anaphylactic reactions, bronchial asthma, and shock secondary to adrenocortical insufficiency or shock unresponsive to conventional therapy where adrenocortical insufficiency may be present: 100 mg to 500 mg by intravenous injection over a period of one to ten minutes, the dose depending on the severity of the condition. The SPC gives this single range across all of its licensed indications and states no separate figure for any individual indication.
Route: Intravenous injection, intravenous infusion or intramuscular injection — the preferred method for initial emergency use is intravenous injection. Not recommended for intrathecal or epidural use.
Frequency: May be repeated at intervals of 2, 4 or 6 hours as indicated by the patient's response and clinical condition.
Max: 500 mg per intravenous injection — the top of the SPC's usual 100-500 mg range. No absolute daily ceiling is stated; what the label caps is duration rather than dose, with high-dose corticosteroid therapy in general continued only until the patient's condition has stabilised, usually not beyond 48 to 72 hours.
Dosage requirements are variable and must be individualised on the basis of the disease under treatment, its severity and the response of the patient over the entire duration of treatment, using the lowest dose that controls the condition for the minimum period; the maintenance dose is found by decreasing the initial dose in small decrements at appropriate intervals until the lowest dose maintaining an adequate clinical response is reached. Following the initial emergency period, consideration should be given to a longer-acting injectable preparation or an oral preparation. If therapy must continue beyond 48 to 72 hours, hypernatraemia may occur and it may be preferable to replace hydrocortisone with a corticosteroid such as methylprednisolone sodium succinate, as little or no sodium retention occurs with it. Peptic ulceration may occur even with high-dose short-term therapy, and prophylactic antacid therapy may be indicated. After long-term therapy the drug must be withdrawn gradually rather than abruptly. Corticosteroid therapy is an adjunct to, and not a replacement for, conventional therapy. Preparation: for injection, add not more than 2 ml of sterile water for injections to one vial, shake and withdraw; for infusion, prepare that solution and then add it to 100 ml to 1000 ml (but not less than 100 ml) of 5% dextrose in water, isotonic saline, or 5% dextrose in isotonic saline if the patient is not on sodium restriction. Elderly patients need no change in dosage, but treatment should be planned bearing in mind the more serious consequences of corticosteroid side-effects in old age, with close clinical supervision.

Paediatric dose

Dose: Not weight-based — governed by the severity of the condition and the response of the patient rather than by age or body weight; the dose may be reduced for infants and children, but should not be less than 25 mg daily
Route: Intravenous injection, intravenous infusion or intramuscular injection — the preferred method for initial emergency use is intravenous injection
Frequency: As indicated by the patient's response and clinical condition
The SPC gives no milligram-per-kilogram paediatric dose and no paediatric maximum, so none is recorded here and no weight calculator applies. §4.2, verbatim: 'While the dose may be reduced for infants and children, it is governed more by the severity of the condition and response of the patient than by age or body weight but should not be less than 25 mg daily.' The 25 mg daily figure is a floor, not a target dose.

Dose adjustments

Renal

Not stated — no renal-impairment dosing statement appears in any fetched section of this SPC. Verify against the full SPC before advising.

Hepatic

§4.2, verbatim: 'In patients with liver disease, there may be an increased effect (see section 4.4) and reduced dosing may be considered.' No numeric reduced dose is given.

Dose independently re-sourced from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — clinician-reviewed. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

  • Known hypersensitivity to the active substance or any of the excipients listed in section 6.1
  • Systemic fungal infection, unless specific anti-infective therapy is employed
  • Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids

Side effects

  • Since hydrocortisone is normally employed on a short-term basis it is unlikely that side effects will occur, but the possibility of effects attributable to corticosteroid therapy should be recognised. Every reaction in the label's table is listed at frequency 'not known'.
  • Infections and neoplasms: opportunistic infection; Kaposi's sarcoma has been reported in patients receiving corticosteroid therapy
  • Endocrine: Cushingoid appearance; hypothalamic pituitary adrenal axis suppression; steroid withdrawal syndrome — too rapid a reduction of dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death, and a withdrawal syndrome of fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and loss of weight may occur
  • Metabolism: metabolic acidosis; sodium retention; water retention; hypokalaemic alkalosis; dyslipidaemia; impaired glucose tolerance; increased insulin or oral hypoglycaemic requirement in diabetics; lipomatosis; increased appetite; weight increased
  • Psychiatric: affective disorders including depression, euphoric mood, affect lability, drug dependence and suicidal ideation; psychotic disorder including mania, delusion, hallucination and aggravation of schizophrenia; mental disorder; personality change; confusional state; anxiety; mood swings; abnormal behaviour; insomnia; irritability
  • Nervous system: epidural lipomatosis; increased intracranial pressure with papilloedema in children (pseudotumour cerebri), usually after treatment withdrawal; benign intracranial hypertension; seizure; amnesia; cognitive disorder; dizziness; headache
  • Eye: central serous chorioretinopathy; cataract; glaucoma; exophthalmos; blurred vision; increased intraocular pressure with possible damage to the optic nerve; corneal or scleral thinning; exacerbation of ophthalmic viral or fungal disease. Ear: vertigo
  • Cardiovascular and respiratory: congestive cardiac failure in susceptible patients; myocardial rupture following a myocardial infarction; hypertrophic cardiomyopathy in prematurely born infants; thrombosis including thromboembolism; hypertension; hypotension; pulmonary embolism; hiccups
  • Blood and immune: leucocytosis; drug hypersensitivity; anaphylactic reaction; anaphylactoid reaction
  • Gastrointestinal: peptic ulceration, with possible perforation

Monitoring

  • Adrenal suppression after treatment — patients subjected to severe stress following corticoid therapy should be observed closely for signs and symptoms of adrenocortical insufficiency
  • Dose titration — undesirable effects may be minimised by using the lowest effective dose for the minimum period, and frequent patient review is required to titrate the dose against disease activity
  • Infection — corticosteroids may increase susceptibility to infection, may mask some signs of infection, exacerbate existing infections and increase the risk of reactivation of latent infections; the clinical presentation may be atypical and may reach an advanced stage before being recognised, so monitor for the development of infection
  • Withdrawal — adrenal cortical atrophy develops during prolonged therapy and may persist for months after stopping treatment. In patients who have received more than physiological doses (approximately 30 mg hydrocortisone) for more than 3 weeks, withdrawal should not be abrupt, and clinical assessment of disease activity may be needed during withdrawal
  • Withdrawal thresholds — once a daily dose of 30 mg hydrocortisone is reached, dose reduction should be slower to allow the HPA axis to recover; abrupt withdrawal of doses up to 160 mg hydrocortisone for 3 weeks is unlikely to lead to clinically relevant HPA-axis suppression in the majority of patients
  • Patient documentation — patients should carry a 'Steroid Treatment' card giving the precautions to be taken and the details of prescriber, drug, dosage and duration of treatment

Clinical monograph

How it works

It binds glucocorticoid receptors to modulate gene transcription, producing broad anti-inflammatory and immunosuppressive effects, and provides physiological corticosteroid replacement in adrenal insufficiency.

Prescribing in practice

  • In suspected adrenal crisis, give parenteral hydrocortisone without delay alongside fluid resuscitation, as treatment is life-saving and should not await confirmatory tests.
  • In anaphylaxis it is a slow-onset adjunct only and must not delay intramuscular adrenaline.
  • It can cause hyperglycaemia, fluid retention, hypokalaemia and, with repeated use, adrenal suppression that must not be stopped abruptly.

Monitoring

Monitor blood glucose, blood pressure, fluid balance and electrolytes, and the clinical response to treatment.

Counselling the patient

  • This steroid is being given urgently to treat a serious reaction or low cortisol level.
  • If you take long-term steroids, never stop them suddenly and carry a steroid alert card.
  • Tell us if you have an infection, as steroids can mask its signs.

Evidence & guidelines

Parenteral hydrocortisone for adrenal crisis is supported by Society for Endocrinology and NICE guidance.

Reference: NICE; RCUK Anaphylaxis 2021; BTS/SIGN Asthma 2023; APROCCHSS Trial NEJM 2018; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Related

Curated clinical cross-links plus same-class fallbacks.

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Featured in these MRCEM clinical pathways

Hydrocortisone is a core drug in the following exam-focused workups on our sister siteReviseMRCEM.

MRCEM Primary / Intermediate / OSCE candidates: each pathway includes exam-style questions, RCEM/NICE citations, and FAQ summaries.