6.3 Corticosteroids

(a) replacement therapy

First Choice:
  • hydrocortisone tablets 10mg, 20mg: the usual dose of hydrocortisone is 10mg on waking and 5mg at 5pm or 6pm.
  • fludrocortisone tablets 100micrograms: usual dose 50–100micrograms daily.
Prescribing Notes
  • In Addison’s disease (primary adrenal failure) hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid) are given. In acute adrenocortical insufficiency, intravenous hydrocortisone sodium succinate 100mg is given every 6–8 hours. The extracellular fluid deficit (usually 3–4 litres) should be replaced by: sodium chloride intravenous infusion 0.9% with glucose intravenous infusion 5%; 1litre is given during the first hour, and the remainder over 12–24 hours.
  • In secondary adrenal failure (hypopituitarism), hydrocortisone is given alone, there being no mineralocorticoid deficiency.
  • Patients deficient in glucocorticoids do not respond adequately to stress and should be advised to double the replacement dose of hydrocortisone for several days if significantly unwell. More serious illnesses or gastro–intestinal disturbances necessitate prompt parenteral hydrocortisone.
(b) pharmacological therapy

First Choice:
  • prednisolone tablets 1mg, 5mg, 25mg; e/c tablets 2.5mg, 5mg; liquid 1mg/mL, 10mg/mL 
  • dexamethasone tablets 500micrograms; soluble tablets, 2mg, 4mg; injection 4mg/mL, 24mg/mL: orally, usual range 0.5–10mg daily. By intramuscular injection or slow intravenous injection or infusion, initially 0.5–20mg.
  • hydrocortisone tablets 10mg, 20mg.
  • methylprednisolone tablets 2mg, 4mg, 16mg, 100mg: usual range, 2–40mg daily.
  • methylprednisolone sodium succinate (Solu–Medrone®) vials 40mg, 125mg, 500mg, 1g, 2g: by slow intravenous injection or infusion, initially 10–500mg.
  • Methylprednisolone acetate (Depo–Medrone®) vials 40mg/mL, 80mg/2mL, 120mg/3mL: deep intramuscular injection into gluteal muscle, 40–120mg, repeated after 2–3 weeks if required.
Prescribing Notes
  • For use of corticosteroids in the treatment of asthma, see section 3.2.
  • For use of corticosteroids in the treatment of musculoskeletal and joint disorders see sections 10.1.2 and 10.2.3.
  • For use of corticosteroids in dermatology, see section 13.4.
  • Patients receiving 7.5mg or more of prednisolone daily (or equivalent; see BNF section 6.3.2) for longer than 3–6 months should receive osteoporosis prophylaxis. No osteoporosis prophylaxis is indicated when corticosteroids are used as replacement therapy. See section 6.6 (c).
  • Care should be taken in reducing pharmacological doses of glucocorticoids if the patient has been treated for longer than 3 weeks to avoid cortisol insufficiency due to prolonged suppression of the hypothalamic–pituitary–adrenal (HPA) axis.
  • In terms of their anti–inflammatory properties, approximately 20mg hydrocortisone is equivalent to 5mg prednisolone or 750micrograms dexamethasone. See BNF section 6.3.2.