Behind the News: Hydrocortisone as a treatment for Covid-19 

In recent days, UK news networks have been sharing a story about new studies hailing Hydrocortisone as a Covid-19 treatment. We asked our medics to review the research and the emerging stories so that we can give you a balanced perspective while also updating you on any impacts to the drug supplies we depend on. 

What has been reported and where? 

BBC News: Coronavirus: Cheap steroids save lives from severe Covid 

Sky News: Coronavirus: Cheap hydrocortisone drug reduces deaths in sickest COVID-19 patients, research finds 

Other news networks have also covered the story. 

Read the article at the heart of the story: 

Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19.  

What the research reveals – our Medic Trustees’ summary 

We are excited to hear that there is more evidence to show that steroids are an effective treatment for some patients with severe Covid-19. This study was a meta-analysis of 7 randomized trials ( that is an analysis of 7 separate trials)  across 12 different countries that included 1703 patients of whom 647 died. The patients being studied had severe Covid-19 and were in an intensive care setting. They were given intravenous dexamethasone, hydrocortisone or a small number had methyl prednisolone. 28-day all-cause mortality was lower among patients who received corticosteroids compared with those who received usual care or placebo. 

What the research doesn’t tell us 

There was no evidence to show hydrocortisone was superior to other steroids.  

What are the implications of hydrocortisone based covid-19 treatment for people with Adrenal Insufficiency? 

Whilst this is exciting news, it does not affect the usual management for patients with adrenal insufficiency and Addison’s disease. Patients should take their replacement steroids in the usual way, doubling up if unwell and taking recommended increased sick day rule doses if unwell with Covid-19. Read our ADSHG advice on Covid-19 for more advice

According to NICE guidance on Covid-19 treatment the Hydrocortisone dose would be 50 mg every 8 hours intravenously. Our Clinical Advisory panel have advised that patients should not worry unduly if their usual doses are not stopped during the treatment.

At the moment we do not anticipate any issues with supplies of hydrocortisone, however please make sure as always you have extra hydrocortisone or prednisolone available so you have enough if unwell. You may also find our article on drug shortages and coping strategies for people with adrenal insufficiency helpful.

We suggest downloading the new NHS Steroid Emergency Card - hard copies are also available for order. When asking for an NHS Steroid Emergency Card to be ordered on your behalf, we recommend including the link to the Society for Endocrinology page as this provides your Health Care Professional with the direct links to order.

NHSE/I are aware of the issues for patients with adrenal insufficiency/Addison’s Disease and we will ensure our ADSHG Clinical Advisory Panel keep in close contact through their links with the relevant Patient Safety teams and keep us updated. 

What is Dexamethasone?

Like hydrocortisone and prednisone, is a corticosteroid.

In the media it has been reported that dexamethasone is a very high dose steroid. How strong is it and what does that mean for people with AI being treated for Covid-19?

The dexamethasone dose for Covid-19 is usually 6mg daily. If someone with AI was on daily steroids and then also given dexamethasone for Covid-19, they may be concerned about how much steroid they are taking.

Although it's tempting to try to assess the total effect of 6mg of dexamethasone added to the daily hydrocortisone people with AI take and draw a conclusion that the doses are unhealthy or dangerous in some way. Calculations like this can be misleading. Healthcare professionals will, while treating AI patients with Covid-19, weigh up each drug's impact on the endocrine system rather than simply the weight of active ingredients in each tablet. For example, many sources on the internet show a comparison on hydrocortisone and dexamethasone that actually relates to their anti-inflammatory properties rather than their endocrine impact. Each steroid can have differing effects on the body depending on the intended use.

While being treated with dexamethasone, it is likely that emergency IV hydrocortisone dosing can stop owing to the coverage provided by dexamethasone being adequate (ie. more than the normal amount healthy people would have in their systems) to cover AI daily dosing. It is vital, of course, to restart hydrocortisone dosing once the dexamethasone treatment is stopped.

It is important to note that during critical illness in intensive care there can be changes to levels of cortisol in the blood. Read about a study that explores this phenomenon. Healthcare professionals need to make careful decisions based on individual levels so that they can reduce the risks of complications like diabetes from administering too much steroid cover.

It is important to continue taking Fludrocortisone throughout treatment as it has an important mineralocorticoid effect which helps regulate blood pressure and salt levels. Dexamethasone does not have this mineralocorticoid effect. Your healthcare professionals may decide if patients are on high doses of hydrocortisone to pause fludrocortisone for a short period of time.

What about tapering back down after these high doses?

It is difficult to be specific about tapering down from these high doses in relation to this treatment regime and resumption of hydrocortisone. Some patients might be well and might only need to double dose for 48 hours and then resume regular doses, others, who may have been ventilated for 10 days, will need longer to get back to normal. It is important to understand that there will be no standard tapering as each case will be different and one cannot second guess every potential scenario. 
There is a lot of information about steroid treatment for people with AI here - is there a quicker summary for my healthcare professionals in case of emergency? 
Yes, the new NHS Steroid Card has a handy QR code that links to information designed specifically for medics in various forms that they will be able to easily refer to as needed. 
Updated 9th December 2020