9 Reminders for Administering Hydrocortisone

• Hydrocortisone is commonly administered in clinical practice.  
• Hydrocortisone should not be used in patients who are hypersensitive to the drug, who have a systemic fungal infection, or premature infants.   
• Side effects of hydrocortisone include, among other ailments, insomnia, anxiety, heartburn, and mood swings. 

From shock to allergies and asthma to ulcerative colitis and hemorrhoids, the drug most commonly used in clinical practice is hydrocortisone.

A corticosteroid with anti-inflammatory, anti-allergy, immunosuppressive, and anti-shock properties, it remains an essential drug in clinical practice. It is also used to manage adrenocortical insufficiency. 

Hydrocortisone is used topically to manage inflammatory dermatosis, atopic dermatitis, adjunctive treatment of ulcerative colitis, inflamed hemorrhoids, skin allergy, and other conditions. The off-label uses of hydrocortisone include treatment of thyroid storm and management of septic shock.

As nurses, we can confuse hydrocortisone, hydrocodone, and hydroxychloroquine. These are three very different drugs from different classes, and we must be vigilant about each one.

Hydrocortisone is sold under the brand names Cortaid, SOLU-Cortef, Cort enema, Cortizone-10, Preparation H Hydrocortisone, Proctocort, Westcort, and Cortef. Avoid mixing these brand names with similar ones, such as Cortef with Coreg or SOLU-Cortef with SOLU-Medrol.

Hydrocortisone belongs to corticosteroids that work by inhibiting the accumulation of inflammatory cells at the inflammation sites, stopping phagocytosis, lysosomal enzyme release and synthesis, and release of inflammatory mediators, showing potent anti-inflammatory effects. It also reverses increased capillary permeability. To prevent inflammation, it suppresses cell-mediated immune reactions and tissue response to inflammation. 

Use of Hydrocortisone in Pregnant Women, Children, and the Elderly 

When given to a pregnant woman, hydrocortisone crosses the placenta and is widely distributed in breast milk. If used chronically in the first trimester during pregnancy, it can raise the chances of cleft palate in the offspring. However, topical use of hydrocortisone is safe in pregnant patients. But ask them to apply it sparingly. It should be used only in the affected area.

In children, a high dosage of long-term hydrocortisone therapy can decrease short-term growth and increase cortisol secretion. In the elderly population, it can put them at risk of developing hypertension and osteoporosis. 

Contraindications of Hydrocortisone

Hydrocortisone should not be used in patients hypersensitive to it, those having a systemic fungal infection that can be exacerbated with corticosteroid therapy, and in premature infants. It shouldn’t be administered if the patient is concurrently injected with a live or attenuated virus vaccine. Intramuscular administration of hydrocortisone is contraindicated in patients with idiopathic thrombocytopenic purpura.  

Hydrocortisone should be given with extreme caution in patients with: thyroid dysfunction, hypertension, liver cirrhosis, osteoporosis, thrombophlebitis or thromboembolic tendencies, heart failure, diabetes, seizures, respiratory tuberculosis, myasthenia gravis, cataracts, glaucoma, increased intraocular pressure, acute myocardial infarction, renal or hepatic impairment, untreated systemic infections, active viral infections. The same goes for elderly patients and immunocompromised patients with diabetes, renal impairment, and open wounds. 

Hydrocortisone should not be applied on post-surgical wounds, cuts, or abrasions, as it can hinder healing. 

Hydrocortisone Interactions 

We all know drug interactions are fundamental. They can alter the effect of the other drug, sometimes potentiating or diminishing. Therefore, it is best to learn about these interactions beforehand and avoid administering them together.

Hydrocortisone can increase the hypokalemic effect when given with diuretics, leading to potassium depletion. In that case, monitor serum potassium closely. With CYP3A4 inducers, such as phenytoin, rifampin, and carbamazepine, the effects of hydrocortisone may decrease. 

When given hydrocortisone therapy, a live vaccine can decrease the patient’s antibody response to the vaccine, which can increase side effects and potentiate virus replication. Tell your patients to wait to receive a vaccine until corticosteroid therapy has stopped, as it interferes with their immune system. Hydrocortisone may also increase the hyponatremic effect of desmopressin.

Hydrocortisone interacts with some herbal drugs. Concomitant administration of St. John’s wort with hydrocortisone may decrease its concentration. In comparison, echinacea may reduce the therapeutic effects of hydrocortisone. 

Hydrocortisone may increase serum glucose, lipid, and sodium levels and decrease serum potassium, calcium, thyroxine, and white blood cell count. Therefore, all these lab reports should be monitored closely with corticosteroid therapy. 

Hydrocortisone Administration 

To reconstitute hydrocortisone sodium succinate, follow the manufacturer’s guidelines. For further dilution, use D5W or 0.9% Sodium Chloride solution. Dilute to 50 mg/ml for an intravenous push and administer over 3 to 5 minutes. For doses greater than 500 mg or greater through an intravenous push, administer over 10 minutes. 

Give intermittent infusion of hydrocortisone sodium succinate in 20 to 30 minutes. Store the vials at room temperature. Once reconstituted, the vials are stable at room temperature for three days. However, the stability becomes concentration-dependent when diluted with dextrose or normal saline. That is 1mg/ml for 24 hours and 2 to 60 mg/ml for four hours. 

The drug should be given with food or milk for oral administration, especially when the patient complains of gastrointestinal distress.

For rectal administration, shake the homogenous suspension of hydrocortisone and instruct the patient to lie on their left side with their left leg extended and right leg flexed. Gently insert the applicator tip into the rectum, pointing slightly towards the umbilicus, and gradually instill the medication.

For topical administration, gently cleanse the area before application. Use occlusive dressings only as ordered. Apply the ointment gently and rub into the area thoroughly so it is well absorbed. 

Intravenous (IV) Compatibilities and Incompatibilities 

For nurses, it is more than essential to know about the compatibilities and incompatibilities of hydrocortisone.

Hydrocortisone has IV incompatibilities with some drugs, such as ciprofloxacin, diazepam, midazolam, and phenytoin. It should not be administered with these drugs. In contrast, it is compatible with various medications, such as amphotericin, calcium gluconate, diphenhydramine, cefepime, digoxin, diltiazem, dopamine, insulin, morphine, lidocaine, magnesium sulfate, lorazepam, norepinephrine, procainamide, propofol, and potassium chloride. 

Side Effects of Hydrocortisone

Side effects of hydrocortisone include insomnia, anxiety, heartburn, aches, diaphoresis, mood swings, increased appetite, increased infection risk, diarrhea or constipation, delayed wound healing, and facial flushing.

Adverse effects are those that the patient cannot tolerate. Be vigilant about distinguishing between side effects and adverse effects. 

When given for a long term, primarily through oral or systemic route, hydrocortisone can cause adverse effects, such as hypocalcemia, muscle wasting, hypokalemia, osteoporosis, cataracts, glaucoma, peptic ulcer, heart failure, and amenorrhea.

Abrupt withdrawal after long-term therapy can cause orthostatic hypotension, weakness, lethargy, rebound inflammation, severe joint pain, nausea, fever, headache, and dizziness. Make sure that your patient does not stop the corticosteroid intake abruptly, as it can lead to a severe adrenal crisis.

Role of Nurses in Hydrocortisone Therapy 

When starting therapy, obtain a baseline assessment, such as body weight, blood pressure, serum glucose, cholesterol level, and serum electrolytes. The patient should also be screened for fungal infections, viral skin lesions, and tuberculosis.

When starting therapy, assess the patient for edema, any signs of fluid retention, hypertension, heart failure, hyperglycemia, and electrolyte imbalance. Be alert to infections since corticosteroids affect the patient’s immune system. Check the patient for symptoms of illness, such as fever, lethargy, and sore throat.

Monitor the patient’s daily pattern of bowel activity and stool consistency. Ask the patient if they have any signs of hypocalcemia, which causes cramps and muscle twitching, or hypokalemia, which causes weakness, and paresthesia. Monitor the patient’s electrocardiogram (ECG) for changes and check if they are irritable or have nausea and vomiting. Also, the patient should be checked for emotional instability and an inability to sleep. 

Patient Teaching  

As a nurse, you serve as a bridge between the doctor and the patient. You counsel the patient about hydrocortisone therapy and tell them what to remember. With hydrocortisone therapy, ask the patient and their caregivers to report fever, sore throat, muscle aches, sudden weight gain, visual disturbances, and behavioral changes to you. Ask them not to take aspirin or any other medication without your permission. Patients should also limit their caffeine intake because hydrocortisone can cause increased diuresis and insomnia.

For topical application, educate the patient to apply hydrocortisone after a shower or bath for best absorption. Moreover, tell them not to cover or use occlusive dressings, tight diapers, plastic pants, and coverings over hydrocortisone ointment after application unless the physician has ordered it. Direct contact with the eyes should also be avoided.   

The Bottom Line

Hydrocortisone is commonly used to relieve eczema and allergies. It’s also used orally and systemically for its anti-inflammatory and immunosuppressive actions. With hydrocortisone therapy, monitor the patient’s serum electrolytes and glucose.

Ask your patients to report any signs of infection promptly and to stop the therapy as directed, as abrupt withdrawal can cause severe adverse effects.  

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