(cortisol) which has glucocorticoid activity and weak
mineralocorticoid activity. It also secretes the
mineralocorticoid aldosterone.
In deficiency states, physiological replacement is best
achieved with a combination of hydrocortisone and the
mineralocorticoid fludrocortisone acetate p. 676;
hydrocortisone alone does not usually provide sufficient
mineralocorticoid activity for complete replacement.
In Addison’s disease or following adrenalectomy,
hydrocortisone by mouth is usually required. This is given in
2 doses, the larger in the morning and the smaller in the
evening, mimicking the normal diurnal rhythm of cortisol
secretion. The optimum daily dose is determined on the
basis of clinical response. Glucocorticoid therapy is
supplemented by fludrocortisone acetate.
In acute adrenocortical insufficiency, hydrocortisone is
given intravenously (preferably as sodium succinate) every
6 to 8 hours in sodium chloride intravenous infusion 0.9%
In hypopituitarism, glucocorticoids should be given as in
adrenocortical insufficiency, but since production of
aldosterone is also regulated by the renin-angiotensin
system a mineralocorticoid is not usually required.
Additional replacement therapy with levothyroxine sodium
p. 773 and sex hormones should be given as indicated by the
pattern of hormone deficiency.
BNF 78 Corticosteroid responsive conditions 671
Glucocorticoid and mineralocorticoid activity
In comparing the relative potencies of corticosteroids in
terms of their anti-inflammatory (glucocorticoid) effects it
should be borne in mind that high glucocorticoid activity in
itself is of no advantage unless it is accompanied by
relatively low mineralocorticoid activity (see Disadvantages
of Corticosteroids). The mineralocorticoid activity of
Equivalent anti-inflammatory doses of
This table takes no account of mineralocorticoid effects, nor
does it take account of variations in duration of action
: Betamethasone 750 micrograms
: Dexamethasone 750 micrograms
The relatively high mineralocorticoid activity of
hydrocortisone p. 676, and the resulting fluid retention,
makes it unsuitable for disease suppression on a long-term
basis. However, hydrocortisone can be used for adrenal
replacement therapy. Hydrocortisone is used on a short-term
basis by intravenous injection for the emergency
management of some conditions. The relatively moderate
anti-inflammatory potency of hydrocortisone also makes it a
useful topical corticosteroid for the management of
inflammatory skin conditions because side-effects (both
topical and systemic) are less marked.
Prednisolone p. 678 and prednisone have predominantly
glucocorticoid activity. Prednisolone is the corticosteroid
most commonly used by mouth for long-term disease
Betamethasone p. 674 and dexamethasone p. 675 have
very high glucocorticoid activity in conjunction with
insignificant mineralocorticoid activity. This makes them
particularly suitable for high-dose therapy in conditions
where fluid retention would be a disadvantage.
Betamethasone and dexamethasone also have a long
duration of action and this, coupled with their lack of
mineralocorticoid action makes them particularly suitable
for conditions which require suppression of corticotropin
(corticotrophin) secretion (e.g. congenital adrenal
Some esters of betamethasone and of beclometasone
dipropionate p. 45 (beclomethasone) exert a considerably
more marked topical effect (e.g. on the skin or the lungs)
than when given by mouth; use is made of this to obtain
topical effects whilst minimising systemic side-effects (e.g.
for skin applications and asthma inhalations).
Deflazacort p. 674 has a high glucocorticoid activity; it is
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
Central serous chorioretinopathy is a retinal disorder
that has been linked to the systemic use of
corticosteroids. Recently, it has also been reported after
local administration of corticosteroids via inhaled and
intranasal, epidural, intra-articular, topical dermal, and
periocular routes. The MHRA recommends that patients
should be advised to report any blurred vision or other
visual disturbances with corticosteroid treatment given
by any route; consider referral to an ophthalmologist for
evaluation of possible causes if a patient presents with
l CONTRA-INDICATIONS Avoid injections containing benzyl
alcohol in neonates . avoid live virus vaccines in those
receiving immunosuppressive doses (serum antibody
response diminished). systemic infection (unless specific
CONTRA-INDICATIONS, FURTHER INFORMATION
For further information on contra-indications associated
with intra-articular, intradermal and intralesional
preparations, consult product literature.
l CAUTIONS Congestive heart failure . diabetes mellitus
to). history of steroid myopathy . history of tuberculosis or
untreated). myasthenia gravis . ocular herpes simplex (risk
infarction (rupture reported). severe affective disorders
CAUTIONS, FURTHER INFORMATION For further information
on cautions associated with intra-articular, intradermal
and intralesional preparations, consult product literature.
reactions . sleep disorders . weight increased
▶ Rare or very rare Malaise .tendon rupture
▶ Frequency not known Chorioretinopathy . growth
retardation (very common in children). intracranial
pressure increased with papilloedema (usually after
SIDE-EFFECTS, FURTHER INFORMATION Adrenal
suppression During prolonged therapy with
corticosteroids, particularly with systemic use, adrenal
atrophy develops and can persist for years after stopping.
Abrupt withdrawal after a prolonged period can lead to
672 Corticosteroid responsive conditions BNF 78
acute adrenal insufficiency, hypotension, or death. To
compensate for a diminished adrenocortical response
caused by prolonged corticosteroid treatment, any
significant intercurrent illness, trauma, or surgical
procedure requires a temporary increase in corticosteroid
dose, or if already stopped, a temporary reintroduction of
corticosteroid treatment. Patients on long-term
corticosteroid treatment should carry a steroid treatment
card which gives guidance on minimising risk and provides
details of prescriber, drug, dosage and duration of
Infections Prolonged courses of corticosteroids
increase susceptibility to infections and severity of
infections; clinical presentation of infections may also be
atypical. Serious infections e.g. septicaemia and
tuberculosis may reach an advanced stage before being
recognised, and amoebiasis or strongyloidiasis may be
activated or exacerbated (exclude before initiating a
corticosteroid in those at risk or with suggestive
symptoms). Fungal or viral ocular infections may also be
Chickenpox Unless they have had chickenpox, patients
receiving oral or parenteral corticosteroids for purposes
other than replacement should be regarded as being at risk
of severe chickenpox. Manifestations of fulminant illness
include pneumonia, hepatitis and disseminated
intravascular coagulation; rash is not necessarily a
prominent feature. Passive immunisation with varicella–
zoster immunoglobulin is needed for exposed non–
immune patients receiving systemic corticosteroids or for
those who have used them within the previous 3 months.
Confirmed chickenpox warrants specialist care and urgent
treatment. Corticosteroids should not be stopped and
dosage may need to be increased.
Measles Patients taking corticosteroids should be
advised to take particular care to avoid exposure to
measles and to seek immediate medical advice if exposure
occurs. Prophylaxis with intramuscular normal
Psychiatric reactions Systemic corticosteroids,
particularly in high doses, are linked to psychiatric
reactions including euphoria, insomnia, irritability, mood
lability, suicidal thoughts, psychotic reactions, and
behavioural disturbances. These reactions frequently
subside on reducing the dose or discontinuing the
corticosteroid but they may also require specific
management. Patients should be advised to seek medical
advice if psychiatric symptoms (especially depression and
suicidal thoughts) occur and they should also be alert to
the rare possibility of such reactions during withdrawal of
corticosteroid treatment. Systemic corticosteroids should
be prescribed with care in those predisposed to psychiatric
reactions, including those who have previously suffered
corticosteroid–induced psychosis, or who have a personal
or family history of psychiatric disorders.
l PREGNANCY The benefit of treatment with corticosteroids
during pregnancy outweighs the risk. Corticosteroid cover
is required during labour. Following a review of the data on
the safety of systemic corticosteroids used in pregnancy
and breast-feeding the CSM (May 1998) concluded that
corticosteroids vary in their ability to cross the placenta
but there is no convincing evidence that systemic
corticosteroids increase the incidence of congenital
abnormalities such as cleft palate or lip. When
administration is prolonged or repeated during pregnancy,
systemic corticosteroids increase the risk of intra-uterine
growth restriction; there is no evidence of intra-uterine
growth restriction following short-term treatment (e.g.
prophylactic treatment for neonatal respiratory distress
syndrome). Any adrenal suppression in the neonate
following prenatal exposure usually resolves
spontaneously after birth and is rarely clinically important.
Monitoring Pregnant women with fluid retention should be
monitored closely when given systemic corticosteroids.
l BREAST FEEDING The benefit of treatment with
corticosteroids during breast-feeding outweighs the risk.
l HEPATIC IMPAIRMENT In general, manufacturers advise
caution (risk of increased exposure).
l RENAL IMPAIRMENT Use by oral and injectable routes
should be undertaken with caution.
▶ In children The height and weight of children receiving
prolonged treatment with corticosteroids should be
monitored annually; if growth is slowed, referral to a
paediatrician should be considered.
l EFFECT ON LABORATORY TESTS May suppress skin test
▶ In adults Abrupt withdrawal after a prolonged period can
lead to acute adrenal insufficiency, hypotension or death.
Withdrawal can also be associated with fever, myalgia,
arthralgia, rhinitis, conjunctivitis, painful itchy skin
nodules and weight loss. The magnitude and speed of dose
reduction in corticosteroid withdrawal should be
determined on a case-by–case basis, taking into
consideration the underlying condition that is being
treated, and individual patient factors such as the
likelihood of relapse and the duration of corticosteroid
treatment. Gradual withdrawal of systemic corticosteroids
should be considered in those whose disease is unlikely to
. received more than 40 mg prednisolone (or equivalent)
. been given repeat doses in the evening;
. received more than 3 weeks’ treatment;
. recently received repeated courses (particularly if taken
. taken a short course within 1 year of stopping long-term
. other possible causes of adrenal suppression.
Systemic corticosteroids may be stopped abruptly in
those whose disease is unlikely to relapse and who have
received treatment for 3 weeks or less and who are not
included in the patient groups described above.
During corticosteroid withdrawal the dose may be
reduced rapidly down to physiological doses (equivalent to
prednisolone 7.5 mg daily) and then reduced more slowly.
Assessment of the disease may be needed during
withdrawal to ensure that relapse does not occur.
▶ In children The magnitude and speed of dose reduction in
condition that is being treated, and individual patient
factors such as the likelihood of relapse and the duration
of corticosteroid treatment. Gradual withdrawal of
systemic corticosteroids should be considered in those
whose disease is unlikely to relapse and have:
. received more than 40 mg prednisolone (or equivalent)
daily for more than 1 week or 2 mg/kg daily for 1 week or
. been given repeat doses in the evening;
. received more than 3 weeks’ treatment;
. recently received repeated courses (particularly if taken
. taken a short course within 1 year of stopping long-term
. other possible causes of adrenal suppression.
Systemic corticosteroids may be stopped abruptly in
those whose disease is unlikely to relapse and who have
received treatment for 3 weeks or less and who are not
included in the patient groups described above.
During corticosteroid withdrawal the dose may be
reduced rapidly down to physiological doses (equivalent to
BNF 78 Corticosteroid responsive conditions 673
prednisolone 2–2.5 mg/m2 daily) and then reduced more
slowly. Assessment of the disease may be needed during
withdrawal to ensure that relapse does not occur.
Advice for patients Patients on long-term corticosteroid
treatment should carry a Steroid Treatment Card which
gives guidance on minimising risk and provides details of
prescriber, drug, dosage and duration of treatment.
A patient information leaflet should be supplied to every
patient when a systemic corticosteroid is prescribed.
Patients should especially be advised of the following:
. Immunosuppression Prolonged courses of
corticosteroids can increase susceptibility to infection
and serious infections can go unrecognised. Unless
already immune, patients are at risk of severe
chickenpox and should avoid close contact with people
who have chickenpox or shingles. Similarly, precautions
should also be taken against contracting measles;
. Adrenal suppression If the corticosteroid is given for
longer than 3 weeks, treatment must not be stopped
abruptly. Adrenal suppression can last for a year or more
after stopping treatment and the patient must mention
the course of corticosteroid when receiving treatment
. Mood and behaviour changes Corticosteroid
treatment, especially with high doses, can alter mood
and behaviour early in treatment—the patient can
become confused, irritable and suffer from delusion and
suicidal thoughts. These effects can also occur when
corticosteroid treatment is being withdrawn. Medical
advice should be sought if worrying psychological
. Other serious effects Serious gastro-intestinal,
musculoskeletal, and ophthalmic effects which require
Steroid treatment cards Steroid treatment cards should be
issued where appropriate. Consider giving a ‘steroid card’
to support communication of the risks associated with
treatment, and specific written advice to consider
corticosteroid replacement during an episode of stress,
such as severe intercurrent illness or an operation, to
patients using greater than maximum licensed doses of
inhaled corticosteroids. Steroid treatment cards are
available for purchase from the NHS Print online ordering
GP practices can obtain supplies through Primary Care
Support England. NHS Trusts can order supplies via the
In Scotland, steroid treatment cards can be obtained
from APS Group Scotland by emailing
stockorders.dppas@apsgroup.co.uk or by fax on 0131 629
l DRUG ACTION Betamethasone has very high glucocorticoid
activity and insignificant mineralocorticoid activity.
Suppression of inflammatory and allergic disorders |
Congenital adrenal hyperplasia
▶ Adult: Usual dose 0.5–5 mg daily
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 4–20 mg, repeated up to 4 times in 24 hours
l INTERACTIONS → Appendix 1: corticosteroids
l SIDE-EFFECTS Hiccups . myocardial rupture (following
recent myocardial infarction). oedema . Stevens-Johnson
l PREGNANCY Readily crosses the placenta. Transient effect
on fetal movements and heart rate.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion (as sodium
phosphate) (Betnesol ®), give continuously or
intermittently or via drip tubing in Glucose 5% or Sodium
▶ With oral use Patient counselling is advised for
betamethasone soluble tablets (steroid card).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 10, 13, 21 (not for use as
mouthwash for oral ulceration)
▶ Betamethasone (Non-proprietary)
Betamethasone (as Betamethasone sodium phosphate)
500 microgram Betamethasone 500microgram soluble tablets sugar
free sugar-free | 100 tablet P £65.18 DT = £58.15
CAUTIONARY AND ADVISORY LABELS 10
▶ Betamethasone (Non-proprietary)
Betamethasone (as Betamethasone sodium phosphate) 4 mg per
1 ml Betamethasone 4mg/1ml solution for injection ampoules | 5 ampoule P £23.93 DT = £23.61
l DRUG ACTION Deflazacort is derived from prednisolone; it
has predominantly glucocorticoid activity.
Suppression of inflammatory and allergic disorders
▶ Adult: Maintenance 3–18 mg daily
Suppression of inflammatory and allergic disorders (acute
▶ Adult: Initially up to 120 mg daily
Inflammatory and allergic disorders
▶ Child 1 month–11 years: 0.25–1.5 mg/kg once daily or on
alternate days; increased if necessary up to 2.4 mg/kg
daily (max. per dose 120 mg), in emergency situations
▶ Child 12–17 years: 3–18 mg once daily or on alternate
days; increased if necessary up to 2.4 mg/kg daily (max.
per dose 120 mg), in emergency situations
l INTERACTIONS → Appendix 1: corticosteroids
Dose adjustments Manufacturer advises adjust to the
l PATIENT AND CARER ADVICE Patient counselling is advised
for deflazacort tablets (steroid card).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet
CAUTIONARY AND ADVISORY LABELS 5, 10
Deflazacort 6 mg Calcort 6mg tablets | 60 tablet P £15.82 DT =
674 Corticosteroid responsive conditions BNF 78
l DRUG ACTION Dexamethasone has very high
glucocorticoid activity and insignificant mineralocorticoid
Suppression of inflammatory and allergic disorders
▶ Child: 150 micrograms/kg for 1 dose
Severe croup (or mild croup that might cause
▶ Child: Initially 150 micrograms/kg for 1 dose, to be
given before transfer to hospital, then (by mouth or by
intravenous injection) 150 micrograms/kg, then (by
mouth or by intravenous injection) 150 micrograms/kg
Congenital adrenal hyperplasia (under expert
▶ Adult: Consult specialist for advice on dosing
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: Consult specialist for advice on dosing
Overnight dexamethasone suppression test
▶ Adult: 1 mg for 1 dose, to be given at night
Adjunctive treatment of bacterial meningitis (starting
before or with first dose of antibacterial)
▶ Adult: 8.3 mg every 6 hours for 4 days
Symptom control of anorexia in palliative care
Dysphagia due to obstruction by tumour in palliative care
Dyspnoea due to bronchospasm or partial obstruction in
Adjunct in the treatment of nausea and vomiting in
Headaches due to raised intracranial pressure in
▶ Adult: 16 mg daily for 4–5 days, then reduced to
4–6 mg daily, reduce dose if possible. To be given
before 6pm to reduce the risk of insomnia
Pain due to nerve compression in palliative care
Cerebral oedema associated with malignancy
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 8–16 mg for 1 dose, then (by
intramuscular injection or by intravenous injection)
5 mg every 6 hours until adequate response achieved
then taper-off gradually, use the 3.8 mg/mL injection
Cerebral oedema associated with malignancy
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 8.3 mg for 1 dose, then (by
intramuscular injection) 3.3 mg every 6 hours as
required for 2–4 days, subsequently, reduce dose
gradually and stop over 5–7 days, use the 3.3 mg/mL
injection preparation for this dose
▶ With intravenous use Consult product literature; not
licensed for use in bacterial meningitis.
l INTERACTIONS → Appendix 1: corticosteroids
▶ With oral use Hiccups . hyperglycaemia . myocardial rupture
(following recent myocardial infarction). protein
▶ With parenteral use Perineal irritation (may occur following
the intravenous injection of large doses of the phosphate
l PREGNANCY Dexamethasone readily crosses the placenta.
l DIRECTIONS FOR ADMINISTRATION
▶ With oral use in children For administration by mouth tablets
may be dispersed in water or injection solution given by
▶ With intravenous use in children For intravenous infusion
dilute with Glucose 5% or Sodium Chloride 0.9%; give over
▶ With intravenous use in adults For intravenous infusion
(Dexamethasone, Hospira) give continuously or
intermittently or via drip tubing in Glucose 5% or Sodium
l PRESCRIBING AND DISPENSING INFORMATION
Dexamethasone 3.8 mg/mL Injection has replaced
dexamethasone 4 mg/mL Injection. All dosage
recommendations for intravenous, intramuscular,
intrarticular use or local infiltration; are given in units of
Palliative care ▶ With systemic use in adults For further
information on the use of dexamethasone in palliative
care, see www.medicinescomplete.com/#/content/palliative/
Medicines for Children leaflet: Dexamethasone for croup
www.medicinesforchildren.org.uk/dexamethasone-croup-0
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
▶ Dexamethasone (Non-proprietary)
Dexamethasone (as Dexamethasone sodium phosphate)
2 mg Dexamethasone 2mg soluble tablets sugar free sugar-free | 50 tablet P £30.00–£30.01 DT = £30.01
Dexamethasone (as Dexamethasone sodium phosphate)
4 mg Dexamethasone 4mg soluble tablets sugar free sugar-free |
50 tablet P £60.00–£60.01 DT = £60.01
Dexamethasone (as Dexamethasone sodium phosphate)
▶ Glensoludex (Glenmark Pharmaceuticals Europe Ltd)
Dexamethasone (as Dexamethasone sodium phosphate)
2 mg Glensoludex 2mg soluble tablets sugar-free | 50 tablet P £10.00 DT = £30.01
Dexamethasone (as Dexamethasone sodium phosphate)
4 mg Glensoludex 4mg soluble tablets sugar-free | 50 tablet P £20.00 DT = £60.01
Dexamethasone (as Dexamethasone sodium phosphate)
8 mg Glensoludex 8mg soluble tablets sugar-free | 50 tablet P £40.00 DT = £120.01
CAUTIONARY AND ADVISORY LABELS 10, 21
▶ Dexamethasone (Non-proprietary)
Dexamethasone 500 microgram Dexamethasone 500microgram
tablets | 28 tablet P £9.51–£54.24 DT = £10.27 | 30 tablet P £11.00–£64.82
BNF 78 Corticosteroid responsive conditions 675
£84.64 | 100 tablet P £160.00–£170.00
£120.00 | 100 tablet P £230.00–£240.00
▶ Neofordex (Aspire Pharma Ltd)
Dexamethasone 40 mg Neofordex 40mg tablets | 10 tablet P £200.00 DT = £200.00
CAUTIONARY AND ADVISORY LABELS 10
▶ Dexamethasone (Non-proprietary)
Dexamethasone (as Dexamethasone sodium phosphate) 3.3 mg
per 1 ml Dexamethasone (base) 6.6mg/2ml solution for injection
ampoules | 10 ampoule P £22.00 DT = £22.00
Dexamethasone (base) 6.6mg/2ml solution for injection vials | 5 vial P £24.00 DT = £24.00
Dexamethasone (base) 3.3mg/1ml solution for injection ampoules |
5 ampoule P £12.00 | 10 ampoule P £15.00–£22.78 DT =
Dexamethasone (as Dexamethasone sodium phosphate) 3.8 mg
per 1 ml Dexamethasone (base) 3.8mg/1ml solution for injection vials
| 10 vial P £19.99–£20.00 DT = £20.00
CAUTIONARY AND ADVISORY LABELS 10, 21
▶ Dexamethasone (Non-proprietary)
Dexamethasone (as Dexamethasone sodium phosphate)
400 microgram per 1 ml Dexamethasone 2mg/5ml oral solution
sugar free sugar-free | 150 ml P £42.30 DT = £42.30
Dexamethasone (as Dexamethasone sodium phosphate) 2 mg per
Dexamethasone (as Dexamethasone sodium phosphate) 4 mg
per 1 ml Dexamethasone 20mg/5ml oral solution sugar free sugarfree | 50 ml P £49.50 DT = £49.50
▶ Dexsol (Rosemont Pharmaceuticals Ltd)
Dexamethasone (as Dexamethasone sodium phosphate)
▶ Martapan (Martindale Pharmaceuticals Ltd)
Dexamethasone (as Dexamethasone sodium phosphate)
400 microgram per 1 ml Martapan 2mg/5ml oral solution sugarfree | 150 ml P £35.96 DT = £42.30
Fludrocortisone acetate 21-Dec-2017
l DRUG ACTION Fludrocortisone has very high
mineralocorticoid activity and insignificant glucocorticoid
Neuropathic postural hypotension
▶ Adult: 100–400 micrograms daily
Mineralocorticoid replacement in adrenocortical
▶ Adult: 50–300 micrograms once daily
Adrenocortical insufficiency resulting from septic shock
(in combination with hydrocortisone)
l UNLICENSED USE Not licensed for use in neuropathic
l INTERACTIONS → Appendix 1: corticosteroids
l SIDE-EFFECTS Conjunctivitis . idiopathic intracranial
hypertension . muscle weakness .thrombophlebitis
Monitoring Monitor patient closely in hepatic impairment.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, capsule, oral
CAUTIONARY AND ADVISORY LABELS 10
▶ Fludrocortisone acetate (Non-proprietary)
Fludrocortisone acetate 100 microgram Fludrocortisone
100microgram tablets | 30 tablet P £13.60 DT = £13.60
l DRUG ACTION Hydrocortisone has equal glucocorticoid
and mineralocorticoid activity.
Thyrotoxic crisis (thyroid storm)
▶ Adult: 100 mg every 6 hours, to be administered as
Adrenocortical insufficiency resulting from septic shock
▶ Adult: 50 mg every 6 hours, given in combination with
Acute hypersensitivity reactions such as angioedema of
the upper respiratory tract and anaphylaxis (adjunct to
▶ Adult: 100–300 mg, to be administered as sodium
Corticosteroid replacement, in patients who have taken
more than 10 mg prednisolone daily (or equivalent)
within 3 months of minor surgery under general
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: Initially 25–50 mg, to be administered at
induction of surgery, the patient’s usual oral
corticosteroid dose is recommenced after surgery
Corticosteroid replacement, in patients who have taken
more than 10 mg prednisolone daily (or equivalent)
within 3 months of moderate or major surgery
▶ INITIALLY BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Adult: Initially 25–50 mg, to be administered at
induction of surgery (following usual oral
corticosteroid dose on the morning of surgery),
followed by (by intravenous injection) 25–50 mg
3 times a day for 24 hours after moderate surgery and
for 48–72 hours after major surgery
Adrenocortical insufficiency in Addison’s disease or
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 20–30 mg daily in 2 divided doses, the larger
dose to be given in the morning and the smaller in the
evening, mimicking the normal diurnal rhythm of
cortisol secretion, the optimum daily dose is
determined on the basis of clinical response
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 100–500 mg 3–4 times a day or when required
Severe inflammatory bowel disease
▶ BY SLOW INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Adult: 100–500 mg 3–4 times a day or when required
676 Corticosteroid responsive conditions BNF 78
Replacement in adrenocortical insufficiency
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: 20–30 mg once daily, adjusted according to
response, dose to be taken in the morning
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 20–30 mg daily in divided doses, adjusted
Ulcerative colitis | Proctitis | Proctosigmoiditis
▶ Adult: Initially 1 metered application 1–2 times a day
for 2–3 weeks, then reduced to 1 metered application
once daily on alternate days, to be inserted into the
Acute hypersensitivity reactions | Angioedema
▶ BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
▶ Child 1–5 months: Initially 25 mg 3 times a day, adjusted
▶ Child 6 months–5 years: Initially 50 mg 3 times a day,
adjusted according to response
▶ Child 6–11 years: Initially 100 mg 3 times a day, adjusted
▶ Child 12–17 years: Initially 200 mg 3 times a day,
adjusted according to response
Severe acute asthma | Life-threatening acute asthma
▶ Child 1 month–1 year: 4 mg/kg every 6 hours (max. per
dose 100 mg), alternatively 25 mg every 6 hours until
conversion to oral prednisolone is possible, dose given,
preferably, as sodium succinate
▶ Child 2–4 years: 4 mg/kg every 6 hours (max. per dose
100 mg), alternatively 50 mg every 6 hours until
conversion to oral prednisolone is possible, dose given,
preferably, as sodium succinate
▶ Child 5–11 years: 4 mg/kg every 6 hours (max. per dose
100 mg), alternatively 100 mg every 6 hours until
conversion to oral prednisolone is possible, dose given,
preferably, as sodium succinate
▶ Child 12–17 years: 4 mg/kg every 6 hours (max. per dose
100 mg), alternatively 100 mg every 6 hours until
conversion to oral prednisolone is possible, dose given,
preferably, as sodium succinate
▶ Adult: 100 mg every 6 hours until conversion to oral
prednisolone is possible, dose given, preferably, as
DOSE EQUIVALENCE AND CONVERSION
▶ When switching from immediate-release
hydrocortisone tablets to modified release Plenadren ®
use same total daily dose. Bioavailability of Plenadren ®
lower than immediate release tablets—monitor clinical
▶ With rectal use Systemic absorption may occur
l INTERACTIONS → Appendix 1: corticosteroids
▶ With oral use Dyslipidaemia . myocardial rupture (following
recent myocardial infarction). oedema
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children For intravenous
administration, dilute with Glucose 5% or Sodium Chloride
0.9%. For intermittent infusion give over 20–30 minutes.
▶ With intravenous use in adults For intravenous infusion
(SoluCortef ®), give continuously or intermittently or via
drip tubing in Glucose 5% or Sodium chloride 0.9%.
l PATIENT AND CARER ADVICE Patient counselling is advised
for hydrocortisone tablets and injections (steroid card).
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
▶ With oral use in adults The Scottish Medicines Consortium has
advised (December 2016) that hydrocortisone modified
release (Plenadren ®) is not recommended for use within
NHS Scotland for treatment of adrenal insufficiency in
adults as there was insufficient evidence submitted.
l LESS SUITABLE FOR PRESCRIBING
▶ With intravenous use Hydrocortisone as the sodium
phosphate is less suitable for prescribing as paraesthesia
and pain (particularly in the perineal region) may follow
l EXCEPTIONS TO LEGAL CATEGORY
▶ With intramuscular use or intravenous use Prescription only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
CAUTIONARY AND ADVISORY LABELS 10, 22, 25
▶ Plenadren (Shire Pharmaceuticals Ltd)
Hydrocortisone 5 mg Plenadren 5mg modified-release tablets | 50 tablet P £242.50 DT = £242.50
Hydrocortisone 20 mg Plenadren 20mg modified-release tablets | 50 tablet P £400.00 DT = £400.00
▶ Hydrocortisone (Non-proprietary)
Hydrocortisone (as Hydrocortisone sodium phosphate)
10 mg Hydrocortisone 10mg soluble tablets sugar free sugar-free | 30 tablet P £37.50
CAUTIONARY AND ADVISORY LABELS 10, 21
▶ Hydrocortisone (Non-proprietary)
Hydrocortisone 10 mg Hydrocortisone 10mg tablets | 30 tablet P £84.45 DT = £20.75
Hydrocortisone 20 mg Hydrocortisone 20mg tablets | 30 tablet P £147.26 DT = £79.36
Hydrocortisone 10 mg Hydventia 10mg tablets | 30 tablet P £15.50 DT = £20.75
Hydrocortisone 20 mg Hydventia 20mg tablets | 30 tablet P £59.95 DT = £79.36
Powder for solution for injection
Hydrocortisone (as Hydrocortisone sodium succinate)
100 mg Solu-Cortef 100mg powder for solution for injection vials | 10 vial P £9.17
▶ Hydrocortistab (Advanz Pharma)
Hydrocortisone acetate 25 mg per 1 ml Hydrocortistab 25mg/1ml
suspension for injection ampoules | 10 ampoule P £68.72 DT =
Powder and solvent for solution for injection
CAUTIONARY AND ADVISORY LABELS 10
Hydrocortisone (as Hydrocortisone sodium succinate)
100 mg Solu-Cortef 100mg powder and solvent for solution for
injection vials | 1 vial P £1.16 DT = £1.16
CAUTIONARY AND ADVISORY LABELS 10
▶ Hydrocortisone (Non-proprietary)
Hydrocortisone (as Hydrocortisone sodium phosphate) 100 mg
per 1 ml Hydrocortisone sodium phosphate 100mg/1ml solution for
injection ampoules | 5 ampoule P £10.60 DT = £10.60
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