Hydrocortisone is a corticosteroid medication that mimics the action of cortisol, a hormone naturally produced by the adrenal glands. Corticosteroids have anti-inflammatory and immunosuppressive properties, making them useful in the treatment of a variety of medical conditions.

Hydrocortisone (Solu Cortef) or cortisol is a corticosteroid that is used to treat various inflammatory, immune-mediated, and allergic diseases.

Hydrocortisone (Solu Cortef) Uses:

• Allergic states:
  • Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in drug hypersensitivity reactions, serum sickness, transfusion reactions, perennial or seasonal allergic rhinitis, or acute noninfectious laryngeal edema (epinephrine is the drug of the first choice).
• Dermatologic diseases:
  • Atopic dermatitis;
  • contact dermatitis;
  • bullous dermatitis herpetiformis;
  • exfoliative dermatitis;
  • severe erythema multiforme (Stevens-Johnson syndrome);
  • exfoliative erythroderma;
  • pemphigus;
  • severe psoriasis;
  • severe seborrheic dermatitis;
  • mycosis fungoides.
• Edematous states:
  • To induce diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus.
• Endocrine disorders:
  • Acute adrenocortical insufficiency;
  • congenital adrenal hyperplasia;
  • nonsuppurative thyroiditis;
  • primary or secondary adrenocortical insufficiency;
  • hypercalcemia associated with cancer;
  • preoperatively and in the event of serious trauma or illness, in patients with known adrenal insufficiency or when the adrenocortical reserve is doubtful;
  • shock unresponsive to conventional therapy if adrenocortical insufficiency exists or is suspected.
• GI diseases:
  • To tide the patient over a critical period of the disease in ulcerative colitis and regional enteritis.
• Hematologic disorders:
  • Acquired (autoimmune) hemolytic anemia;
  • erythroblastopenia (RBC anemia);
  • immune thrombocytopenia (formerly known as idiopathic thrombocytopenic purpura) in adults;
  • congenital (erythroid) hypoplastic anemia (Diamond Blackfan anemia);
  • pure red cell aplasia;
  • select cases of secondary thrombocytopenia.
• Neoplastic diseases:
  • Palliative management of leukemias and lymphomas (adults);
  • acute leukemia of childhood.
• Nervous system:
  • Acute exacerbations of multiple sclerosis;
  • cerebral edema associated with a primary or metastatic brain tumor, or craniotomy.

Note: Treatment guidelines recommend the use of high-dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis.

• Ophthalmic diseases:
  • Severe acute and chronic allergic and inflammatory processes involving the eye, such as:
    • allergic conjunctivitis;
    • anterior segment inflammation;
    • chorioretinitis;
    • allergic corneal marginal ulcers;
    • diffuse posterior uveitis and choroiditis;
    • herpes zoster ophthalmicus;
    • optic neuritis;
    • sympathetic ophthalmia;
    • iritis and iridocyclitis;
    • keratitis;
    • other ocular inflammatory conditions unresponsive to topical corticosteroids.
• Respiratory diseases:
  • Aspiration pneumonitis;
  • bronchial asthma;
  • berylliosis;
  • idiopathic eosinophilic pneumonia;
  • Loeffler syndrome (not manageable by other means);
  • fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy;
  • symptomatic sarcoidosis.
• Rheumatic disorders:
  • As adjunctive therapy for short-term administration in:
    • acute and subacute bursitis,
    • acute gouty arthritis,
    • epicondylitis,
    • posttraumatic osteoarthritis,
    • acute nonspecific tenosynovitis,
    • ankylosing spondylitis psoriatic arthritis,
    • rheumatoid arthritis,
    • including juvenile rheumatoid arthritis,
    • synovitis of osteoarthritis;
    • during an exacerbation or as maintenance therapy in acute rheumatic carditis,
    • dermatomyositis (polymyositis),
    • temporal arteritis, and
    • systemic lupus erythematosus.
• Miscellaneous:
  • Trichinosis with neurologic or myocardial involvement;
  • tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy.
• Off Label Use of Hydrocortisone in Adults:
  • Septic shock
  • Thyroid storm
  • In-hospital cardiac arrest

Hydrocortisone (Solu Cortef) Dose in Adults

Note:

• Use hydrocortisone as directed by your doctor, adjusting the dose based on your condition and how you respond to the treatment.
• It's important to use the smallest effective dose to manage your condition, and if your symptoms improve, your doctor may gradually reduce the dose.
• In critical situations, higher doses through injection may be necessary for immediate relief.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute exacerbation of Asthma (off-label dose):

• Take it by mouth, splitting the total dose into smaller amounts, usually 200 mg, for 5 to 7 days.
• This might help during a bad asthma episode, but always follow your doctor's advice and the recommended guidelines for the best results.

Hydrocortisone (Solu Cortef) Dose as an Anti-inflammatory or immunosuppressive:

• If given through injection into the muscle (IM) or into a vein (IV), the initial dose typically ranges from 100 to 500 mg, with intervals between doses of 2, 4, or 6 hours.
• If taken orally, the initial dose is in the range of 20 to 240 mg per day.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute adrenal insufficiency (adrenal crisis):

• This involves an initial 100 mg dose given directly into the vein (IV) followed by 25 to 75 mg every 6 hours, or a continuous IV infusion of 200 mg over 24 hours.
• This immediate treatment is crucial for stabilizing the patient, and after the first day, the dose may be gradually reduced.
• Once the patient is stable, they may switch to oral medication for ongoing maintenance.
• It's important to note that proper fluid resuscitation is also necessary during this treatment.

Hydrocortisone (Solu Cortef) Dose in the treatment of Chronic adrenal insufficiency (eg, primary, secondary, classic congenital adrenal hyperplasia):

• The recommended dose ranges from 15 to 25 mg orally per day, divided into 2 to 3 doses.
• It is usually advised to administer the largest dose in the morning upon waking up, followed by the next dose 2 hours after lunch if using a 2-dose regimen.
• Alternatively, if using a 3-dose regimen, the next dose can be taken at lunch, followed by the smallest dose in the afternoon, ideally no later than 4 to 6 hours before bedtime.

Hydrocortisone (Solu Cortef) Dose in the treatment of Adrenal insufficiency (temporary), physiologic replacement following resection of an ACTH-producing tumor or unilateral adrenalectomy (off-label dose):

• The recommended dose is oral, ranging from 10 to 12 mg per square meter of body surface area per day, divided into 2 to 3 doses.
• It's important to take the first dose as soon as possible after waking up.
• This treatment is typically continued until the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the body's stress response, recovers.
• In general, HPA axis recovery may take 6 to 12 months following resection of ACTH-producing tumors or 18 months following unilateral adrenalectomy.

Hydrocortisone (Solu Cortef) Dose in the treatment of acute exacerbations of multiple sclerosis:

• The recommended dose of methylprednisolone for acute exacerbations of multiple sclerosis, as per treatment guidelines, involves either intramuscular (IM) or intravenous (IV) administration of 800 mg per day for one week, followed by 320 mg every other day for one month.
• Alternatively, an oral regimen may include 200 mg per day for one week, followed by 80 mg every other day for one month.

Hydrocortisone (Solu Cortef) Dose during Sickness:

• In cases of illness with fever, the oral hydrocortisone dose is typically doubled for a fever above 38°C (100.4°F) and tripled for a fever above 39°C (102.2°F).
• This increased dose is maintained until recovery, and then the patient can return to their standard dose within 1 to 2 days.
• This strategy helps to ensure sufficient cortisol levels during times of increased stress, such as illness with fever, to prevent complications associated with adrenal insufficiency.

Hydrocortisone (Solu Cortef) Dose in the treatment of Gastroenteritis with vomiting and/or diarrhea:

• In the treatment of gastroenteritis with vomiting and/or diarrhea, hydrocortisone may be administered through intramuscular (IM) or subcutaneous (SubQ) injection.
• The recommended dose is 100 mg, given early in the course of the illness.
• This initial dose can be repeated after 6 to 12 hours if necessary.
• The use of hydrocortisone in this context may help address inflammation and stress caused by the illness.

Hydrocortisone (Solu Cortef) Dose in the treatment of Severe infection (eg, pneumonia with altered cognition):

• In the treatment of severe infection, such as pneumonia, particularly in cases where there is altered cognition, hydrocortisone may be administered through intramuscular (IM) or subcutaneous (SubQ) injection.
• The recommended dose is 100 mg, given early in the course of the illness.
• This initial dose can be repeated after 6 to 12 hours until recovery.
• The use of hydrocortisone in severe infections may help modulate the immune response and reduce inflammation.

Hydrocortisone (Solu Cortef) Dose in Surgery:

• Minor Stress (e.g., inguinal herniorrhaphy):
  • Method: Intravenous (IV)
  • Dose: 25 mg/day for 1 day
• Moderate Stress (e.g., joint replacement, cholecystectomy):
  • Method: IV
  • Dose: 50 to 75 mg/day (25 mg every 8 to 12 hours) for 1 to 2 days
• Major Stress (e.g., pancreatoduodenectomy, esophagogastrectomy, cardiac surgery):
  • Method: IV
  • Dose: 100 to 150 mg/day (50 mg every 8 to 12 hours) for 2 to 3 days

Hydrocortisone (Solu Cortef) Dose in the treatment of Septic shock (off-label):

• Indication: Septic shock not responding to volume resuscitation and vasopressors.
• Administration (IV):
  • Initial Bolus: 50 mg every 6 hours
  • Continuous Infusion: 200 mg/day
• Duration: Guidelines suggest a therapy duration of ≥3 days, with most studies treating for up to 7 days. Not all studies tapered therapy.
• Combination Therapy: Can be used alone or in combination with fludrocortisone.
• Considerations:
  • Tapering: Consider a slow taper over several days when vasopressors are no longer required to avoid potential hemodynamic deterioration.
  • Monitoring: Watch for possible side effects such as hyperglycemia and hypernatremia, especially with low-dose hydrocortisone.
  • Continuous Infusion: Some studies recommend dosing by continuous infusion to manage side effects.

Hydrocortisone (Solu Cortef) Dose in the treatment of Thyroid storm (off-label):

• Indication: Thyroid storm (off-label use).
• Administration (IV):
  • Loading Dose: 300 mg initially
  • Maintenance Dose: 100 mg every 8 hours

Note: The use of hydrocortisone in the treatment of thyroid storm is an off-label application.

Hydrocortisone (Solu Cortef) Dose in Childrens

Note:

• Adjust the medication dose based on the specific condition and how the patient is responding.
• Use the smallest effective dose to manage the condition.
• If you can reduce the dose, do it gradually.
• In critical situations where the patient's life is at risk, larger doses given through injections might be necessary, and these could be higher than what is taken by mouth.

Hydrocortisone (Solu Cortef) Dose in the treatment of Acute Adrenal Insufficiency (adrenal crisis):

• Weight-directed Dosage:
  • Infants, Children, and Adolescents: Initial 2 to 3 mg/kg (up to a maximum of 100 mg per dose), then for infants, 1 to 5 mg/kg every 6 hours. For children and adolescents, refer to BSA- or age-directed dosing. Intravenous (IV) or intraosseous (I.O.) administration can be considered if necessary.
• BSA-directed Dosage:
  • Infants, Children, and Adolescents: Initial 50 to 100 mg/m² followed by 50 to 100 mg/m² per day in 4 divided doses.
• Age-directed Dosage (Fixed Dosing):
  • Infants: 10 to 25 mg initially, followed by 10 to 25 mg/day in divided doses every 6 hours for 24 hours. Subsequent dose reductions and rate adjustments based on patient response.
  • Children <5 years: 25 to 50 mg initially, followed by 25 to 50 mg/day in divided doses every 6 hours for 24 hours. Subsequent dose reductions and rate adjustments based on patient response.
  • Children ≥5 years: 50 to 100 mg initially, followed by 50 mg/day in divided doses every 6 hours for 24 hours. Subsequent dose reductions and rate adjustments based on patient response.
  • Adolescents: 100 mg initially, followed by 100 mg/day in divided doses every 6 hours for 24 hours. Subsequent dose reduction and rate adjustments based on patient response.

Note: Dosage adjustments should be made based on the patient's condition and response. The goal is to use the lowest effective dose to control the condition, and reductions should be gradual.

Hydrocortisone (Solu Cortef) Dose as Anti-inflammatory or immunosuppressive:

• Infants and Children:
  • Oral: 2.5 to 10 mg/kg/day or 75 to 300 mg/m²/day divided every 6 to 8 hours.
  • IM, IV (Manufacturer's labeling): Initial 0.56 to 8 mg/kg/day or 20 to 240 mg/m²/day in 3 or 4 divided doses.
  • IM, IV (Alternate dosing): Limited data available; 1 to 5 mg/kg/day or 30 to 150 mg/m²/day divided every 12 to 24 hours.
• Adolescents:
  • Oral, IM, IV, SubQ: 15 to 240 mg every 12 hours.

Note: The dosing range is broad, and the exact dose depends on the disease being treated and the patient's individual response.

Hydrocortisone (Solu Cortef) Dose in the treatment of Congenital adrenal hyperplasia:

• Initial Dose (Oral Tablets):
  • 10 to 15 mg per square meter of body surface area per day, divided into 3 doses.
  • Higher initial doses (up to 20 mg/m²/day) might be needed initially to reach target hormone levels.
• Maintenance Dose (Oral Tablets):
  • Infants: 2.5 to 5 mg per dose, three times a day.
  • Children: 5 to 10 mg per dose, three times a day.
  • Adolescents (fully grown): 15 to 25 mg per day, divided into 2 to 3 doses.

Note: It's crucial to give the morning dose as early as possible. Tablets are preferred for more reliable concentrations, and the use of oral suspension is not recommended. The dose should be adjusted based on the individual's growth, hormone levels, and bone age. Additionally, some individuals may need mineralocorticoid (like fludrocortisone) and sodium supplements, especially if they have salt-losing forms of congenital adrenal hyperplasia.

Hydrocortisone (Solu Cortef) Dose in the Physiologic replacement:

• Oral:
  • 8 to 10 mg per square meter of body surface area per day, divided every 8 hours.
  • Some patients may require up to 12 mg/m²/day.
  • To mimic the natural daily variation, the highest doses are usually given in the morning, with the midday dose being a bit lower, and the lowest dose in the evening.

It's important to individualize the dose based on the child's specific needs, and this approach helps replicate the natural diurnal (daily) rhythm of cortisol production in the body.

Hydrocortisone (Solu Cortef) Dose as supplemental for Stress dosing: Limited data available; dosage regimens variable:

• Age-directed Dosing for Moderate Stress in Patients with Congenital Adrenal Hyperplasia (Endocrine Society):
  • Infants and preschool children (IV):
    • Initial dose: 25 mg once, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose, divided every 6 hours.
  • School-age children (IV):
    • Initial dose: 50 mg once, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose, divided every 6 hours.
  • Adolescents (IV):
    • Initial dose: 100 mg once, followed by a daily dose that is 3 to 4 times the patient's standard maintenance dose, divided every 6 hours.
• BSA-directed Dosing (Shulman):
  • Mild to moderate stress (Oral, IM, IV):
    • 20 to 50 mg/m²/day divided into 3 or 4 doses. Lower-end doses (20 to 30 mg/m²/day) may be divided twice daily.
  • Major stress or surgery (Oral, IM, IV):
    • 100 mg/m²/day in divided doses every 6 hours.
  • Planned surgery (IV or IM):
    • Pre-anesthesia dose of 50 mg/m² administered 30 to 60 minutes before surgery, followed by a second dose of 50 mg/m² as a continuous IV infusion or in divided doses every 6 hours for at least 24 hours.

These dosages are meant to support the body during times of stress and should be tailored to the individual patient's needs.

Hydrocortisone (Solu Cortef) Dose in the Septic shock; catecholamine-refractory with suspected/proved adrenal insufficiency: Limited data available:

For septic shock that is catecholamine-refractory with suspected or proved adrenal insufficiency in infants, children, and adolescents, the hydrocortisone dose is as follows:

• Intravenous (IV):
  • Standard Dose: 50 to 100 mg per square meter of body surface area per day.
  • Titration in Some Cases: In certain situations, doses may be titrated up to 50 mg/kg/day if necessary for shock reversal.
  • Note: Efficacy data with higher doses (up to 50 mg/kg/day) are variable.

Solu Cortef (Hydrocortisone) Pregnancy Risk Factor: C

• Corticosteroids have been associated with adverse effects in animal reproduction studies, and there are mixed findings regarding the impact of first-trimester systemic corticosteroid use on oral clefts or birth weight in humans, possibly influenced by maternal dose and the reason for use.
• Newborns of mothers who used corticosteroids during pregnancy may experience hypoadrenalism.
• When managing adrenal insufficiency in pregnant women, hydrocortisone is the preferred corticosteroid, with doses possibly needing adjustment during pregnancy, and stress doses may be necessary during labor.
• Pregnant women with adrenal insufficiency should be monitored regularly.
• Uncontrolled asthma during pregnancy poses risks such as perinatal mortality, preeclampsia, and preterm birth.
• Inhaled corticosteroids are recommended for asthma treatment in pregnancy, but systemic corticosteroids like hydrocortisone may be needed for acute exacerbations.
• For rheumatic disorders or dermatologic conditions during pregnancy, systemic corticosteroids should be used cautiously, preferably at the lowest effective dose and for the shortest duration, especially avoiding high doses in the first trimester.

Hydrocortisone use during breastfeeding:

• Corticosteroids are found in breast milk, and when used systemically by nursing mothers, they can potentially lead to adverse effects in the breastfed infant, such as growth suppression and interference with the infant's natural corticosteroid production.
• Single doses of hydrocortisone are generally considered acceptable during breastfeeding, but there is limited data on the effects of prolonged use.
• In usual doses, corticosteroids are generally considered acceptable for breastfeeding, although monitoring the infant is recommended.
• To minimize potential exposure, some guidelines suggest waiting for four hours after the maternal dose of an oral systemic corticosteroid before breastfeeding.
• This recommendation is based on a study involving prednisolone.

Hydrocortisone (Solu Cortef) Dose in Kidney disease:

• The manufacturer's labeling does not provide specific dosage adjustments for individuals with renal impairment.
• However, it is advised to use the medication with caution in such cases.

Hydrocortisone (Solu Cortef) Dose in Liver disease:

• The manufacturer's labeling does not specify dosage adjustments for individuals with hepatic impairment.
• However, it recommends using the medication with caution in such cases.

Side effects of Hydrocortisone (Solu Cortef):

• Cardiovascular:
  • Cardiac Arrhythmia
  • Cardiac Failure (Especially In Susceptible Patients)
  • Cardiomegaly
  • Circulatory Shock
  • Hypertension
  • Hypertrophic Cardiomyopathy (Premature Infants)
  • Atheromatous Embolism
  • Bradycardia
  • Myocardial Rupture (Post-Myocardial Infarction)
  • Syncope
  • Tachycardia
  • Thromboembolism
  • Thrombophlebitis
  • Vasculitis
• Central Nervous System:
  • Emotional Lability
  • Euphoria
  • Headache
  • Increased Intracranial Pressure (With Pseudotumor Cerebri; Usually Following Discontinuation)
  • Insomnia
  • Malaise
  • Arachnoiditis (Intrathecal Administration)
  • Depression
  • Meningitis (Intrathecal Administration)
  • Myasthenia
  • Neuritis
  • Neuropathy
  • Paraplegia (Intrathecal Administration)
  • Paresthesia
  • Personality Changes
  • Psychic Disorder
  • Seizure
  • Sensory Disturbance (Intrathecal Administration)
  • Tingling Of Skin (Especially In The Perineal Area After IV Injection)
  • Vertigo
• Dermatologic:
  • Alopecia
  • Atrophic Striae
  • Burning Sensation Of Skin (Especially In The Perineal Area After IV Injection)
  • Diaphoresis
  • Ecchymosis
  • Erythema (Including Facial)
  • Exfoliation Of Skin
  • Acne Vulgaris
  • Allergic Dermatitis
  • Hyperpigmentation
  • Hypertrichosis
  • Hypopigmentation
  • Skin Atrophy
  • Skin Rash
  • Suppression Of Skin Test Reaction
  • Urticaria
  • Xeroderma
• Endocrine & Metabolic:
  • Diabetes Mellitus (Latent)
  • Fluid Retention
  • Glycosuria
  • Growth Suppression
  • Hirsutism
  • Adrenal Suppression
  • Cushing Syndrome
  • HPA-Axis Suppression
  • Hypercalcemia (Associated With Cancers)
  • Hyperglycemia (Including Increased Requirements For Insulin Or Oral Hypoglycemic Agents In Diabetes Mellitus)
  • Hypokalemia
  • Hypokalemic Alkalosis
  • Impaired Glucose Tolerance
  • Lipodystrophy
  • Lipomatosis (Epidural)
  • Menstrual Disease (Menstrual Irregularities)
  • Moon Face
  • Negative Nitrogen Balance
  • Protein Catabolism
  • Sodium Retention
  • Weight Gain
• Gastrointestinal:
  • Gastrointestinal Disease (Intrathecal Administration)
  • Gastrointestinal Perforation (Small And Large Intestine
  • Particularly In Patients With Inflammatory Bowel Disease)
  • Hiccups
  • Increased Appetite
  • Nausea
  • Pancreatitis
  • Abdominal Distention
  • Carbohydrate Intolerance
  • Dyspepsia
  • Peptic Ulcer (With Possible Perforation And Hemorrhage)
  • Ulcerative Esophagitis
  • Vomiting
• Genitourinary:
  • Asthenospermia
  • Bladder Dysfunction (Intrathecal Administration)
• Hematologic & Oncologic:
  • Leukocytosis
  • Petechia
• Hepatic:
  • Hepatomegaly
  • Increased Serum Transaminases (Usually Mild Elevations And Reversible On Discontinuation)
• Hypersensitivity:
  • Anaphylaxis
  • Angioedema
  • Hypersensitivity Reaction
• Infection:
  • Increased Susceptibility To Infection
  • Infection
  • Sterile Abscess
• Local:
  • Atrophy At Injection Site (Cutaneous And Subcutaneous)
  • Postinjection Flare (Intra-Articular Use)
  • Skin Edema
• Neuromuscular & Skeletal:
  • Osteoporosis
  • Pathological Fracture (Long Bones)
  • Rupture Of Tendon (Particularly Achilles Tendon)
  • Steroid Myopathy
  • Amyotrophy
  • Charcot-Like Arthropathy
  • Lower Extremity Weakness (Intrathecal Administration)
  • Osteonecrosis (Aseptic Necrosis Of Femoral And Humoral Heads)
  • Vertebral Compression Fracture
• Ophthalmic:
  • Exophthalmos
  • Glaucoma
  • Increased Intraocular Pressure
  • Cataract (Posterior Subcapsular)
  • Retinopathy (Central Serous Chorioretinopathy)
• Respiratory:
  • Pulmonary Edema
• Miscellaneous:
  • Wound Healing Impairment

Contraindications to Hydrocortisone (Solu Cortef):

• Hydrocortisone is contraindicated in individuals with hypersensitivity to hydrocortisone or any component of the formulation, systemic fungal infections, premature infants (specifically in formulations containing benzyl alcohol), idiopathic thrombocytopenia purpura (with intramuscular administration only), intrathecal administration, and when receiving live or live attenuated virus vaccines along with immunosuppressive doses of corticosteroids.

• In Canadian labeling, additional contraindications include herpes simplex of the eye (except for short-term or emergency therapy), vaccinia, and varicella (except for short-term or emergency therapy).

• While documentation of allergenic cross-reactivity for corticosteroids is limited, the potential for cross-sensitivity cannot be ruled out due to similarities in chemical structure and pharmacologic actions.

Warnings and precautions

Suppression of the adrenals:

• Hydrocortisone may lead to adrenal suppression, causing excessive cortisol levels or inhibiting the normal functioning of the hypothalamic-pituitary-adrenal (HPA) axis, especially in younger children or those on high doses for extended periods.
• This suppression of the HPA axis could potentially result in adrenal crisis.
• When discontinuing hydrocortisone, it's crucial to do so gradually and with care to avoid complications.
• Special attention is needed when switching patients from systemic corticosteroids to inhaled products due to the risk of adrenal insufficiency or withdrawal symptoms, which may include an increase in allergic reactions.
• Patients taking more than 20 mg per day of prednisone (or equivalent) may be particularly susceptible to these effects.
• Fatalities have been reported in asthmatic patients during and after the transition from systemic corticosteroids to aerosol steroids, as aerosol steroids don't provide the systemic steroid support necessary for situations like trauma, surgery, or infections.

Anaphylactoid reactions

• In rare instances, some individuals receiving corticosteroids, including hydrocortisone, have experienced anaphylactoid reactions.
• These reactions involve symptoms similar to anaphylaxis, which is a severe and potentially life-threatening allergic reaction.
• It's essential for individuals using corticosteroids to be aware of the signs of anaphylactoid reactions, such as difficulty breathing, swelling, or a sudden drop in blood pressure, and seek immediate medical attention if these symptoms occur.

Dermal changes:

• When using hydrocortisone, it's important to avoid injection or leakage into the dermis, as this can lead to dermal and/or subdermal skin depression at the injection site.
• Additionally, it is advisable to avoid deltoid muscle injection, as subcutaneous atrophy (loss of tissue under the skin) may occur.
• These precautions are crucial to prevent unwanted changes in the skin associated with the administration of hydrocortisone.

Immunosuppression:

• Prolonged use of corticosteroids like hydrocortisone can weaken the immune system, increasing the risk of secondary infections.
• It may also mask signs of acute infections, including fungal infections, and make viral infections last longer or worsen.
• The response to certain vaccines may be limited.
• It's important to avoid exposure to chickenpox or measles when using corticosteroids.
• They should not be used for conditions like cerebral malaria, fungal infections, or viral hepatitis.
• Close monitoring is necessary for patients with latent tuberculosis or a history of TB exposure, and their use should be restricted in active TB cases.

Kaposi Sarcoma:

• There have been case reports associating prolonged treatment with corticosteroids, such as hydrocortisone, with the development of Kaposi sarcoma.
• If signs of Kaposi sarcoma are observed, discontinuation of corticosteroid therapy should be considered.

Myopathy

• High doses of corticosteroids, including hydrocortisone, have been associated with the development of acute myopathy, particularly in individuals with neuromuscular transmission disorders.
• This condition may affect muscles, including those involved in eye movement and respiration.
• Monitoring creatine kinase levels is recommended in such cases, as it can be an indicator of muscle damage.
• It's important to be aware of the symptoms of myopathy, which may include muscle weakness and difficulty breathing, and to seek medical attention if these signs occur.
• Recovery from corticosteroid-induced myopathy may be delayed, underscoring the importance of close monitoring and prompt medical intervention when necessary.

Psychiatric disorders:

• The use of corticosteroids, like hydrocortisone, may lead to psychiatric disturbances, encompassing a range of effects such as euphoria, insomnia, mood swings, personality changes, severe depression, or psychotic manifestations.
• Pre-existing psychiatric conditions can also be exacerbated by the use of corticosteroids.

Cardiovascular disease

• Caution is advised when using hydrocortisone in patients with heart failure (HF) and/or hypertension, as it has been linked to fluid retention, electrolyte disturbances, and elevated blood pressure.
• Following an acute myocardial infarction (MI or heart attack), the use of corticosteroids, including hydrocortisone, should be approached with caution due to an association with the risk of myocardial rupture.

Diabetes:

• Corticosteroids, including hydrocortisone, should be used with caution in patients with diabetes mellitus.
• These medications have the potential to affect glucose production and regulation, which can lead to elevated blood sugar levels (hyperglycemia).

Gastrointestinal Disease:

• Caution is advised when using hydrocortisone in patients with gastrointestinal diseases, including diverticulitis, recent intestinal anastomoses, active or latent peptic ulcers, ulcerative colitis, or abscesses or other pyogenic infections.
• Corticosteroids, including hydrocortisone, may increase the risk of perforation in the gastrointestinal tract in individuals with these conditions.

Head injury

• In cases of head injury, it is important to note that increased mortality has been observed in patients receiving high-dose intravenous (IV) methylprednisolone.
• As a result, high-dose corticosteroids, including hydrocortisone, are not recommended for the management of head injuries.

Hepatic impairment

• Hydrocortisone should be used with caution in patients with hepatic impairment, including cirrhosis.
• Long-term use of corticosteroids, including hydrocortisone, has been associated with fluid retention, and individuals with hepatic impairment may be at an increased risk of this side effect.

Myasthenia gravis:

• Hydrocortisone should be used with caution in patients with myasthenia gravis, a neuromuscular disorder.
• Exacerbation of symptoms, especially during the initial stages of treatment with corticosteroids, has been reported.

Ocular disease:

• Hydrocortisone should be used with caution in patients with ocular conditions such as cataracts and/or glaucoma.
• Prolonged use of corticosteroids, including hydrocortisone, has been associated with increased intraocular pressure, open-angle glaucoma, and cataracts.
• Oral steroid treatment is not recommended for the treatment of acute optic neuritis, as it may increase the frequency of new episodes and does not impact short- or long-term visual outcomes.
• Caution is also advised in patients with ocular herpes simplex, as the use of corticosteroids may lead to corneal perforation.
• Hydrocortisone should not be used in cases of active ocular herpes simplex.
• Routine eye exams are recommended for individuals on chronic corticosteroid therapy to monitor for potential ocular side effects.

Osteoporosis

• Hydrocortisone should be used with caution in patients with osteoporosis, a condition characterized by decreased bone density.
• High doses and/or long-term use of corticosteroids, including hydrocortisone, have been associated with increased bone loss and an elevated risk of osteoporotic fractures.

Pheochromocytoma:

• The use of corticosteroids, including hydrocortisone, should be approached with caution in individuals with suspected pheochromocytoma.
• Pheochromocytoma crisis, a potentially fatal condition, has been reported in association with corticosteroid administration.
• Healthcare providers should carefully consider the risk of pheochromocytoma crisis before prescribing corticosteroids in patients with suspected pheochromocytoma.
• It is essential to thoroughly evaluate the individual's medical history and potential risk factors before initiating corticosteroid therapy.
• If there are concerns or suspicions regarding pheochromocytoma, appropriate diagnostic testing and consultation with specialists may be necessary.

Renal impairment

• Hydrocortisone should be used with caution in patients with renal impairment, as the medication may lead to fluid retention.
• Individuals with impaired kidney function may be more susceptible to this side effect.

Seizure disorders:

• Corticosteroids, including hydrocortisone, should be used cautiously in individuals with a history of seizure disorders.

Sepsis or septic shock syndrome:

• Corticosteroids, including hydrocortisone, should not be administered for the treatment of sepsis in the absence of shock.
• This recommendation emphasizes that corticosteroids are not indicated for the treatment of sepsis without concurrent shock.

Thyroid disease:

• In individuals with thyroid disease, changes in thyroid status may require adjustments to the dosage of corticosteroids, including hydrocortisone.
• The metabolic clearance of corticosteroids tends to increase in individuals with hyperthyroidism (overactive thyroid) and decrease in those with hypothyroidism (underactive thyroid).

Hydrocortisone (systemic): Drug Interaction

Risk Factor C (Monitor therapy)
Acetylcholinesterase Inhibitors	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur.
Amphotericin B	Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B.
Androgens	Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
Bile Acid Sequestrants	May decrease the absorption of Corticosteroids (Oral).
Calcitriol (Systemic)	Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic).
Coccidioides immitis Skin Test	Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test.
Corticorelin	Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy.
CYP3A4 Inducers (Strong)	May decrease the serum concentration of Hydrocortisone (Systemic).
CYP3A4 Inhibitors (Strong)	May increase the serum concentration of Corticosteroids (Systemic).
Deferasirox	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Deferasirox	Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Denosumab	May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased.
DilTIAZem	May increase the serum concentration of Corticosteroids (Systemic).
Erdafitinib	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Estrogen Derivatives	May increase the serum concentration of Corticosteroids (Systemic).
Indacaterol	May enhance the hypokalemic effect of Corticosteroids (Systemic).
Isoniazid	Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid.
Loop Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics.
Lumacaftor	May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Nicorandil	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination.
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective).
Nonsteroidal Anti-Inflammatory Agents (Nonselective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).
Ocrelizumab	May enhance the immunosuppressive effect of Immunosuppressants.
P-glycoprotein/ABCB1 Inducers	May decrease the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inducers may also further limit the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
P-glycoprotein/ABCB1 Inhibitors	May increase the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of pglycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
Pidotimod	Immunosuppressants may diminish the therapeutic effect of Pidotimod.
Quinolones	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased.
Ranolazine	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Ritodrine	Corticosteroids may enhance the adverse/toxic effect of Ritodrine.
Salicylates	May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity.
Sargramostim	Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim.
Siponimod	Immunosuppressants may enhance the immunosuppressive effect of Siponimod.
Somatropin	Corticosteroids (Systemic) may diminish the therapeutic effect of Somatropin.
Tacrolimus (Systemic)	Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase.
Tertomotide	Immunosuppressants may diminish the therapeutic effect of Tertomotide.
Thiazide and Thiazide-Like Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Trastuzumab	May enhance the neutropenic effect of Immunosuppressants.
Urea Cycle Disorder Agents	Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range.
Warfarin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin.
Risk Factor D (Consider therapy modification)
Antacids	May decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects.
Aprepitant	May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment.
Axicabtagene Ciloleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity.
Baricitinib	Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted.
Cosyntropin	Hydrocortisone (Systemic) may diminish the diagnostic effect of Cosyntropin. Management: Patients receiving hydrocortisone should omit their pre-test dose on the day selected for cosyntropin testing.
Desirudin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation.
Echinacea	May diminish the therapeutic effect of Immunosuppressants.
Fingolimod	Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections).
Fosaprepitant	May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect.
Hyaluronidase	Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required.
Leflunomide	Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly.
Mitotane	May decrease the serum concentration of Corticosteroids (Systemic).
Neuromuscular-Blocking Agents (Nondepolarizing)	May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur.
Nivolumab	Immunosuppressants may diminish the therapeutic effect of Nivolumab.
Roflumilast	May enhance the immunosuppressive effect of Immunosuppressants.
Sipuleucel-T	Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy.
Tisagenlecleucel	Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome).
Tofacitinib	Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants.
Vaccines (Inactivated)	Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation.
Vaccines (Live)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided.
Risk Factor X (Avoid combination)
Aldesleukin	Corticosteroids may diminish the antineoplastic effect of Aldesleukin.
BCG (Intravesical)	Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical).
Cladribine	May enhance the immunosuppressive effect of Immunosuppressants.
Desmopressin	Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin.
Indium 111 Capromab Pendetide	Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide.
Macimorelin	Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin.
Mifamurtide	Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide.
MiFEPRIStone	May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (e.g., for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment.
Natalizumab	Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased.
Pimecrolimus	May enhance the adverse/toxic effect of Immunosuppressants.
Tacrolimus (Topical)	May enhance the adverse/toxic effect of Immunosuppressants.

Monitoring parameters:

Serum Glucose and Electrolytes:

• Regularly check blood sugar levels.
• Monitor electrolyte balance.

Blood Pressure and Weight:

• Keep track of blood pressure changes.
• Monitor weight for signs of fluid retention.

Infection Presence:

• Be vigilant for signs of infection.
• Early detection and management are crucial.

Intraocular Pressure (IOP):

• If therapy extends beyond 6 weeks, monitor IOP.
• Particularly important for those at risk of glaucoma.

Bone Mineral Density:

• Assess bone health regularly.
• High doses or long-term use may impact bone density.

HPA Axis Suppression:

• Evaluate HPA axis function.
• Utilize tests such as ACTH stimulation, morning cortisol, or urinary cortisol.

Pediatric Growth:

• Monitor growth in pediatric patients.
• Assess any impact on normal development.

Regular and comprehensive monitoring helps ensure the effective and safe use of hydrocortisone, allowing timely adjustments to the treatment plan when needed.

How to administer Hydrocortisone (Solu Cortef)?

Oral Administration:

• Administer with food or milk.
• Helps reduce gastrointestinal (GI) upset.

Parenteral Administration (IM or IV):

• Dermal Effects:
  • Watch for skin depression at the injection site.
• IM Injection:
  • Avoid the deltoid muscle to prevent subcutaneous atrophy.
• IV Bolus:
  • Administer undiluted over at least 30 seconds.
  • For large doses (≥500 mg), extend the administration time to 10 minutes.
• IV Intermittent Infusion:
  • Further dilute in a compatible fluid.
  • Administer over 20 to 30 minutes.

Following these guidelines enhances the safety and effectiveness of hydrocortisone administration.

Mechanism of action of Hydrocortisone (Solu Cortef):

• Hydrocortisone is a corticosteroid that acts quickly and has low sodium-retaining effects.
• It works by reducing inflammation through two main mechanisms: suppressing the movement of certain white blood cells (polymorphonuclear leukocytes) and reversing the increased permeability of tiny blood vessels.
• By doing so, hydrocortisone helps manage various conditions by alleviating inflammation, making it a valuable medication in treating a range of medical issues.

Onset of Action:

• IV administration shows an onset of action within 1 hour.

Absorption:

• Hydrocortisone is rapidly absorbed.

Bioavailability:

• Oral bioavailability is high at approximately 96% ± 20% (Czock 2005).

Distribution:

• Volume of distribution (V) for IV administration is around 27 ± 7 L (Czock 2005).

Protein Binding:

• IV administration results in approximately 92% ± 2% protein binding (Czock 2005).

Metabolism:

• The liver is the primary site of metabolism.

Half-life Elimination:

• IV: Approximately 2 ± 0.3 hours.
• Oral: Approximately 1.8 ± 0.5 hours (Czock 2005).

Time to Peak, Plasma:

• Oral administration reaches peak plasma levels in about 1.2 ± 0.4 hours (Czock 2005).

Excretion:

• Primarily excreted through the urine (Czock 2005).

Understanding these pharmacokinetic details helps guide the appropriate use and dosing of hydrocortisone in clinical settings.

International Brand Names of Hydrocortisone:

• Cortef
• Solu-CORTEF
• Cortifoam
• Cortin
• Cortis-100
• Cortisol
• Cortisol L.C.H.
• Cortisona
• Covocort
• Dhartisone100
• Drosodin
• Efcorlin
• Entofoam
• Fartison
• Flebocortid
• Flemex
• Actocortina
• Aftasone
• Arvisone
• Biocort
• Cipcorlin
• Clovisone
• Colifoam
• Colofoam
• Corhydron
• Coripen
• Cort-S
• Cortaject
• Cortef
• Fridalit
• Harond
• Hidrocort
• Hidrocortif
• Hidrocortizon
• Hidrotisona
• Hison
• Hycort
• Hycortil
• Hydrocort
• Hydrocortistab
• Hydrosone
• Hydrotopic
• Hyson
• Hysone
• Kortef
• Lyo-Cortin
• M-Cort
• Nositrol
• Oralsone
• Plenadren
• Primacor
• Primacort
• Rapicort
• Rapison
• Rolak
• Samcort
• Saxizon
• Solhidrol
• Solu Cortef
• Solu-Cortef
• Solu-Tisone
• Stericort
• Unicort
• Zonac
• Zycort

Hydrocortisone Brand Names in Pakistan:

Hydrocortisone Injection 100 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
Cortisol	Bio Pharma
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hydro Sod Suc	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrocort	Akhai Pharmaceuticals.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.
Solu-Hydrocort	Haji Medicine Co.

Hydrocortisone Injection 200 Mg
Cortisol	Bio Pharma

Hydrocortisone Injection 250 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
H-Cortisone	Mediate Pharmaceuticals (Pvt) Ltd
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hydro Sod Suc	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrocort	Akhai Pharmaceuticals.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.
Solu-Hydrocort	Haji Medicine Co.
Solu-Hydrocort	Haji Medicine Co.

Hydrocortisone Injection 500 Mg
Bio-Cort	Ipram International
Cartilan	Pharmedic (Pvt) Ltd.
H-Cortisone	Mediate Pharmaceuticals (Pvt) Ltd
Hy-Cortisone	Cirin Pharmaceuticals (Pvt) Ltd.
Hyzonate	Amson Vaccines & Pharma (Pvt) Ltd.
Solu Cortef	Pfizer Laboratories Ltd.

Hydrocortisone Eye Drops 1 %W/V
Hydrocortisone	Lahore Chemical & Pharmaceutical Works (Pvt) Ltd

Hydrocortisone Oint 1 %W/W
Hycortisone	Mediceena Pharma (Pvt) Ltd.

Hydrocortisone Cream 1 %W/W
Clozole-H	Pearl Pharmaceuticals
Cortiderm	Valor Pharmaceuticals
Cortiderm	Valor Pharmaceuticals
Cutis-Hc	Derma Techno Pakistan
Gen-Cot	Biogen Pharma
Hydrocort 1.0%	Atco Laboratories Limited
Hydrocort 1.0%	Atco Laboratories Limited
Hydrocortisone	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
Hydrogray	Gray`S Pharmaceuticals
Hydroheal	Webros Pharmaceuticals
Hydrosone	Ferozsons Laboratoies Ltd.
Hydrovate	Pearl Pharmaceuticals

Hydrocortisone Cream 2 %W/W
Cortival	Valor Pharmaceuticals
Hydrosone	Ferozsons Laboratoies Ltd.

Hydrocortisone Cream 2.5 %W/W
Hydrocort 2.5%	Atco Laboratories Limited