Rev. 07/03

Rx Only

DESCRIPTION

Glucocorticoids are adrenocortical steroids, both naturally occurring and synthetic, which are readily absorbed from the gastrointestinal tract.

Hydrocortisone is a white to practically white, odorless, crystalline powder, very slightly soluble in water. The molecular weight is 362.47. It is designated chemically as 11B, 17,21-trihydroxy-pregn-4-ene-3,20-dione. The molecular formula is C21H30O5 and the structural formula is:

Hydrocortisone is believed to be the principal hormone secreted by the adrenal cortex.

Each tablet for oral administration contains 20 mg of hydrocortisone.

Inactive Ingredients: Anhydrous Lactose, Colloidal Silicon Dioxide, Magnesium Stearate, Microcrystalline Cellulose, and Sodium Starch Glycolate.

CLINICAL PHARMACOLOGY

Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. They are also used for their potent anti-inflammatory effects in disorders of many organ systems.

Glucocorticoids cause profound and varied metabolic effects. In addition, they modify the body's immune responses to diverse stimuli.

INDICATIONS AND USAGE

1. Endocrine Disorders  Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the first choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy mineralocorticoid supplementation is of particular importance)   Congenital adrenal hyperplasia   Nonsuppurative thyroiditis   Hypercalcemia associated with cancer
2. Rheumatic Disorders  As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in:   Psoriatic arthritis   Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy):   Ankylosing spondylitis   Acute and subacute bursitis   Acute nonspecific tenosynovitis   Acute gouty arthritis   Post-traumatic osteoarthritis   Synovitis or osteoarthritis   Epicondylitis
3. Collagen Diseases  During an exacerbation or as maintenance therapy in selected cases of:   Systemic lupus erythematosus   Acute rheumatic carditis   Systemic dermatomyositis (polymyositis)
4. Dermatologic Diseases  Pemphigus   Bullous dermatitis herpetiformis   Severe erythema multiforme (Stevens-Johnson syndrome)   Exfoliative dermatitis   Mycosis fungoides   Severe psoriasis   Severe seborrheic dermatitis
5. Allergic States  Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment:   Seasonal or perennial allergic rhinitis   Bronchial asthma   Contact dermatitis   Atopic dermatitis   Serum sickness   Drug hypersensitivity reactions
6. Ophthalmic Diseases  Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa, such as:   Allergic conjunctivitis   Keratitis   Allergic corneal marginal ulcers   Herpes zoster ophthalmicus   Iritis and iridocyclitis   Chorioretinitis   Anterior segment inflammation   Diffuse posterior uveitis and choroiditis   Optic neuritis   Sympathetic ophthalmia
7. Respiratory Disease  Symptomatic sarcoidosis   Loeffler's syndrome not manageable by other means   Berylliosis   Fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculosis chemotherapy   Aspiration pneumonitis
8. Hematologic Disorder  Idiopathic thrombocytopenic purpura in adults   Secondary thrombocytopenia in adults   Acquired (autoimmune) hemolytic anemia   Erythroblastopenia (RBC anemia)   Congenital (erythroid) hypoplastic anemia
9. Neoplastic Disease  For palliative management of:   Leukemias and lymphomas in adults   Acute leukemia of childhood
10. Edematous States  To induce a diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus
11. Gastrointestinal Diseases  To tide the patient over a critical period of the disease in:   Ulcerative colitis   Regional enteritis
12. Miscellaneous  Tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy   Trichinosis with neurologic or myocardial involvement

CONTRAINDICATIONS

 Systemic fungal infections   Hypersensitivity to this product

WARNINGS

Persons who are on drugs which suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in non-immune children or adults on corticosteroids. In such children or adults who have not had these diseases, particular care should be taken to avoid exposure. How the dose, route and duration of corticosteroid administration affects the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information). If chickenpox develops, treatment with antiviral agents may be considered.

In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated.

Drug-induced secondary adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage. This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted. If the patient is receiving steroids already, dosage may have to be increased. Since mineralocorticoid secretion may be impaired, salt and/or a mineralo-corticoid should be administered concurrently.

Corticosteroids may mask some signs of infection, and new infections may appear during their use. There may be decreased resistance and inability to localize infection when corticosteroids are used. Moreover, corticosteroids may affect nitroblue-tetrazolium test for bacterial infection and produce false negative results.

In cerebral malaria, a double-blind trial has shown that the use of corticosteroids is associated with prolongation of coma and higher incidence of pneumonia and gastrointestinal bleeding.

Corticosteroids may activate latent amebiasis. Therefore, it is recommended that latent or active amebiasis be ruled out before initiating corticosteroid therapy in any patient who has spent time in the tropics or any patient with unexplained diarrhea.

Prolonged use of corticosteroids may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves, and may enhance the establishment of secondary ocular infections due to fungi or viruses.

Usage in pregnancy: Since adequate human reproduction studies have not been done with corticosteroids, use of these drugs in pregnancy or in women of childbearing potential requires that the anticipated benefits be weighed against the possible hazards to the mother and embryo or fetus. Infants born of mothers who have received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism.

Corticosteroids appear in breast milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other unwanted effects. Mothers taking pharmacologic doses of corticosteroids should be advised not to nurse.

Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. These effects are less likely to occur with synthetic derivatives except when used in large doses. Dietary salt restriction and potassium supplementation may be necessary. All corticosteroids increase calcium excretion.

Administration of live virus vaccines, including smallpox, is contraindicated in individuals receiving immunosuppressive doses of corticosteroids. If inactivated viral or bacterial vaccines are administered to individuals receiving immunosuppressive doses of corticosteroids, the expected serum antibody response may not be obtained. However, immunization procedures may be undertaken in patients who are receiving corticosteroids as replacement therapy, e.g., for Addison's disease.

The use of hydrocortisone tablets in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for the management of the disease in conjunction with an appropriate antituberculous regimen.

If corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary as reactivation of the disease may occur. During prolonged corticosteroid therapy, these patients should receive chemoprophylaxis.

Literature reports suggest an apparent association between use of corticosteroids and left ventricular free wall rupture after a recent myocardial infarction; therefore, therapy with corticosteroids should be used with great caution in these patients.

PRECAUTIONS

General:

Following prolonged therapy, withdrawal of corticosteroids may result in symptoms of the corticosteroid withdrawal syndrome including fever, myalgia, arthralgia, and malaise. This may occur in patients even without evidence of adrenal insufficiency.

There is an enhanced effect of corticosteroids in patients with hypothyroidism and in those with cirrhosis.

Corticosteroids should be used cautiously in patients with ocular herpes simplex because of possible corneal perforation.

The lowest possible dose of corticosteroid should be used to control the condition under treatment, and when reduction in dosage is possible, the reduction should be gradual.

Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations. Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.

Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia.

Steroids should be used with caution in nonspecific ulcerative colitis, if there is a probability of impending perforation, abscess, or other pyogenic infection, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, renal insufficiency, hypertension, osteoporosis, and myasthenia gravis. Signs of peritoneal irritation following gastrointestinal perforation in patients receiving large doses of corticosteroids may be minimal or absent. Fat embolism has been reported as a possible complication of hypercortisonism.

When large doses are given, some authorities advise that corticosteroids be taken with meals and antacids taken between meals to help to prevent peptic ulcer.

Growth and development of infants and children on prolonged corticosteroid therapy should be carefully observed.

Steroids may increase or decrease motility and number of spermatozoa in some patients.

Phenytoin, phenobarbital, ephedrine, and rifampin may enhance the metabolic clearance of corticosteroids, resulting in decreased blood levels and lessened physiologic activity, thus requiring adjustment in corticosteroid dosage.

The prothrombin time should be checked frequently in patients who are receiving corticosteroids and coumarin anticoagulants at the same time because of reports that corticosteroids have altered the response to these anticoagulants. Studies have shown that the usual effect produced by adding corticosteroids is inhibition of response to courmarins, although there have been some conflicting reports of potentiation not substantiated by studies.

When corticosteroids are administered concomitantly with potassium-depleting diuretics, patients should be observed closely for development of hypokalemia.

Information for Patients:

Persons who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles. Patients should also be advised that if they are exposed, medical advice should be sought without delay.

ADVERSE REACTIONS

Fluid and Electrolyte Disturbances

Sodium retention  
Fluid retention  
Congestive heart failure in susceptible patients  
Potassium loss  
Hypokalemic alkalosis  
Hypertension

Musculoskeletal

Muscle weakness  
Steroid myopathy  
Loss of muscle mass  
Osteoporosis  
Vertebral compression fractures  
Aseptic necrosis of femoral and humeral heads  
Pathologic fracture of long bones  
Tendon rupture

Gastrointestinal

Peptic ulcer with possible perforation and hemorrhage  
Perforation of the small and large bowel, particularly in patients with inflammatory bowel disease  
Pancreatitis  
Abdominal distention  
Ulcerative esophagitis

Dermatologic

Impaired wound healing  
Thin fragile skin  
Petechiae and ecchymoses  
Erythema  
Increased sweating  
May suppress reactions to skin tests  
Other cutaneous reactions, such as allergic dermatitis, urticaria, angioneurotic edema

Neurologic

Convulsions  
Increased intracranial pressure with papilledema (pseudotumor cerbri) usually after treatment
Vertigo  
Headache  
Psychic disturbances

Endocrine

Menstrual irregularities  
Development of cushingoid state  
Suppression of growth in children  
Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery, or illness  
Decreased carbohydrate tolerance  
Manifestations of latent diabetes mellitus  
Increased requirements for insulin or oral hypoglycemic agents in diabetics  
Hirsutism

Ophthalmic

Posterior subcapsular cataracts  
Increased intraocular pressure  
Glaucoma  
Exophthalmos

Metabolic

Negative nitrogen balance due to protein catabolism

Cardiovascular

Myocardial rupture following recent myocardial infarction (see WARNINGS)

Other

Hypersensitivity  
Thromboembolism  
Weight gain  
Increased appetite  
Nausea  
Malaise

OVERDOSAGE

Reports of acute toxicity and/or death following overdosage of glucocorticoids are rare. In the event of overdosage, no specific antidote is available, treatment is supportive and symptomatic.

The intraperitoneal LD50 of hydrocortisone in female mice was 1740 mg/kg.

DOSAGE AND ADMINISTRATION

For oral administration

DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE AND THE RESPONSE OF THE PATIENT.

The initial dosage varies from 20 to 240 mg a day depending on the disease being treated. In less severe diseases doses lower than 20 mg may suffice, while in severe diseases doses higher than 240 mg may be required. The initial dosage should be maintained or adjusted until the patient's response is satisfactory. If satisfactory clinical response does not occur after a reasonable period of time, discontinue hydrocortisone tablets and transfer the patient to other therapy.

After a favorable initial response, the proper maintenance dosage should be determined by decreasing the initial dosage in small amounts to the lowest dosage that maintains an adequate clinical response.

Patients should be observed closely for signs that might require adjustment, including changes in clinical status resulting from remissions or exacerbations of the disease, individual drug responsiveness, and the effect of stress (e.g., surgery, infection, trauma). During stress it may be necessary to increase dosage temporarily.

If the drug is to be stopped after more than a few days of treatment, it usually should be withdrawn gradually.

HOW SUPPLIED

Hydrocortisone Tablets USP 20 mg: White, round, scored tablets; imprinted "West-ward 254".

Bottles of 100 tablets.

Unit Dose Boxes of 100 tablets.

Store at 20-25°C (68-77°F) [See USP Controlled Room Temperature]. Protect from light and moisture.

Dispense in a tight, light-resistant container as defined in the USP using a child-resistant closure.

Manufactured by:
West-ward Pharmaceutical Corp.
Eatontown, N.J. 07724
Revised July 2003

PACKAGE LABEL - HYDROCORTISONE 20 MG TABLET