Replacement therapy in congenital adrenal hyperplasia in children.

For use as replacement therapy in primary, secondary, or acute adrenocortical insufficiency.

Pre-operatively, and during serious trauma or illness in patients with known adrenal insufficiency or doubtful adrenocortical reserve.

Emergency treatment of severe bronchial asthma, drug hypersensitivity reactions, serum sickness, angioneurotic oedema and anaphylaxis in adults and children.

Posology

Dosage must be individualised according to the response of the individual patient. The lowest possible dosage should be used. Doses should be multiples of 10 (i.e. 10mg, 20mg, 30mg, etc.).

Undesirable effects may be minimised by using the lowest effective dose for the minimum period, and by administering the daily requirement as a single morning dose, or whenever possible, as a single morning dose on alternate days. Frequent patient review is required to titrate the dose against disease activity.

To avoid hypoadrenalism and/or a relapse of the underlying disease, it may be necessary to withdraw the drug gradually (see section 4.4).

Replacement therapy

In chronic adrenocortical insufficiency, a dosage of 20 to 30mg a day is usually recommended, sometimes together with 4-6 g of sodium chloride or 50-300 micrograms of fludrocortisone daily.

When immediate support is mandatory, one of the soluble adrenocortical hormone preparations (e.g. dexamethasone sodium phosphate), which may be effective within minutes after parenteral administration, can be life-saving.

Paediatric population:

In congenital adrenal hyperplasia, 10-30 mg in divided doses is the normal daily requirement (see section 4.4).

In chronic adrenocortical insufficiency, the dosage should be approximately 0.4 to 0.8mg/kg/day in two or three divided doses, adjusted to the needs of the individual child (see section 4.4).

In patients requiring replacement therapy, the daily dose should be given when practicable, in two doses. The first dose in the morning should be larger than the second dose in the evening, thus simulating the normal diurnal rhythm of cortisol secretion.

Use in serious trauma or illness with known adrenal insufficiency or doubtful adrenocortical reserve

Paediatric population:

Doses are generally higher than that used for chronic adrenocortical insufficiency and should be selected as appropriate for the clinical situation.

Patients should be observed closely for signs that might require dosage 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 the dosage temporarily.

Pre-operative use

Anaesthetists must be informed if the patient is taking corticosteroids or has previously taken corticosteroids.

When long term treatment is to be discontinued, the dose should be gradually reduced over a period of weeks or months, depending on dosage and duration of therapy (see section 4.4).

Acute emergencies

60-80 mg every 4-6 hours for 24 hours then gradually reduce the dose over several days.

The dosage regimen in adult and pediatric patients should be based on the current guidelines for each condition.

Elderly:

Treatment of elderly patients, particularly if long term, should be planned bearing in mind the more serious consequences of the common side effects of corticosteroids in old age, especially osteoporosis, diabetes, hypertension, susceptibility to infection and thinning of the skin (see section 4.4).

Method of administration

For oral administration.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Contraindicated in infections including systemic infections where anti-infective therapy has not been started.

Patients vaccinated with live vaccines.

A patient information leaflet should be supplied with this product.

Patients should carry 'Steroid Treatment' cards which give clear guidance on the precautions to be taken to minimise risk and which provide details of the prescriber, drug, dosage and the duration of treatment.

The lowest possible dosage of corticosteroids should be used and when reduction in dosage is possible, the reduction should be gradual.

Patients/and or carers should be warned that potentially severe psychiatric adverse reactions may occur with systemic steroids (see section 4.8). Symptoms typically emerge within a few days or weeks of starting the treatment. Risks may be higher with high doses/systemic exposure (see section 4.5), although dose levels do not allow prediction of the onset, type, severity or duration of reactions. Most reactions recover after either dose reduction or withdrawal, although specific treatment may be necessary.

Patients/carers should be encouraged to seek medical advice if worrying psychological symptoms develop, especially if depressed mood or suicidal ideation is suspected.

Patients/carers should also be alert to possible psychiatric disturbances that may occur either during or immediately after dose tapering/withdrawal of systemic steroids, although such reactions have been reported infrequently.

Particular care is required when considering the use of systemic corticosteroids in patients with existing or a previous history of severe affective disorders in themselves or in their first degree relatives. These would include depressive or manic-depressive illness and previous steroid psychosis.

Adrenal suppression

Adrenal cortical atrophy develops during prolonged therapy and may persist for years after stopping treatment. Withdrawal of corticosteroids after prolonged therapy must therefore always be gradual to avoid acute adrenal insufficiency, being tapered off over weeks or months according to the dose and duration of treatment. During transient illnesses such as low grade infection, fever of any aetiology, stressful situations such as minor surgical procedures, the daily replacement dose must be increased temporarily. The patient must be carefully informed how to act in these situations and also advised to immediately seek medical attention should an acute deterioration occur; especially in cases of gastroenteritis, vomiting and/or diarrhoea leading to fluid and salt loss, as well as to inadequate absorption of oral hydrocortisone. If corticosteroids have been stopped following prolonged therapy, they may need to be temporarily re-introduced. Caution should be exercised in immunocompromised patients.

Chickenpox is of particular concern since this normally minor illness may be fatal in immunosuppressed patients. Patients (or parents of children receiving hydrocortisone tablets) without a definite history of chickenpox should be advised to avoid close personal contact with chickenpox or herpes zoster. If exposed they should seek urgent medical attention. Passive immunisation with varicella zoster immunoglobulin (VZIG) is needed by exposed, non-immune patients who are receiving systemic corticosteroids or who have used them within the previous 3 months; this should be given within 10 days of exposure to chickenpox. If a diagnosis of chickenpox is confirmed, the illness warrants specialist care and urgent treatment.

Patients 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 immunoglobulin may be needed.

Patients with concomitant adrenal insufficiency and retroviral infection, such as HIV, need careful dose adjustment due to potential interaction with antiretroviral medicinal products and increased hydrocortisone dose due to the infection.

Live vaccines should not be given to individuals with impaired immune responsiveness caused by high doses of corticosteroids. Killed vaccines or toxoids may be given though their effects may be attenuated.

Corticosteroids should not be stopped and the dose may need to be increased. Corticosteroids may exacerbate systemic fungal infections and therefore should not be used in the presence of such infections unless they are needed to control life-threatening drug reactions due to amphotericin. Moreover, there have been cases reported in which concomitant use of amphotericin and hydrocortisone was followed by cardiac enlargement and congestive failure.

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.

During acute adrenal insufficiency parenteral administration of hydrocortisone in high doses, together with sodium chloride 9 mg/ml (0.9%) solution for injection, must be given.

Average and large dosages 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 the synthetic derivatives except when used in large doses. Dietary salt restriction and potassium supplementation may be necessary. All corticosteroids increase calcium excretion. Long-term treatment with higher than physiological hydrocortisone doses can lead to clinical features resembling Cushing´ s syndrome with increased adiposity, abdominal obesity, hypertension and diabetes and thus result in an increased risk of cardiovascular morbidity and mortality.

A report shows that the use of corticosteroids in cerebral malaria is associated with a prolonged coma and an increased incidence of pneumonia and gastro-intestinal bleeding.

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

The use of hydrocortisone tablets in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis.

Particular care is required when prescribing systemic corticosteroids in patients with the following conditions and frequent patient monitoring is necessary:

• renal insufficiency

• hypertension

• diabetes mellitus or a family history of diabetes

• congestive heart failure

• thrombophlebitis

• exanthematous disease

• chronic nephritis

• acute glomerulonephritis

• metastatic carcinoma

• osteoporosis (postmenopausal patients are at special risk). All glucocorticoids increase calcium excretion and reduce the bone-remodelling rate. Patients with adrenal insufficiency on long-term glucocorticoid replacement therapy have been found to have reduced bone mineral density; severe affective disorders (particularly if there is a history of steroid-induced psychosis)

• epilepsy

• previous steroid myopathy

• liver failure

• glaucoma (or family history of glaucoma).

• myasthenia gravis

• non-specific ulcerative colitis if there is a probability of impending perforation

• diverticulitis

• fresh intestinal anastomoses

• active or latent peptic ulcer

• recent myocardial infarction

Signs of peritoneal irritation following gastro-intestinal perforation in patients receiving large doses of corticosteroids may be minimal or absent.

During treatment, the patient should be observed for psychotic reactions, weakness, electrocardiographic changes, hypertension and untoward hormonal effects.

Fat embolism has been reported as a possible complication of hypercortisonism.

There is an enhanced effect of corticosteroids in patients with hypothyroidism and in those with cirrhosis. Patients with adrenal insufficiency should be monitored for thyroid dysfunction as both hypothyroidism and hyperthyroidism may markedly influence the exposure of administered hydrocortisone.

Treatment of primary adrenal insufficiency often warrants addition of a mineralocorticoid.

Prolonged courses of corticosteroids increase the susceptibility to infections and their severity. The clinical presentation may also be atypical.

Corticosteroids may mask some signs of infection and some serious infection such as septicaemia and tuberculosis may reach an advanced stage before being recognised. New infections may appear during their use. There may be an inability to localise infection in patients on corticosteroids. Corticosteroids may affect the nitrobluetetrazolium test for bacterial infection and produce false negative results.

Corticosteroids may activate latent amoebiasis or strongyloidiasis or exacerbate active disease. Therefore, it is recommended that latent or active amoebiasis and strongyloidiasis be excluded before initiating corticosteroid therapy in any patient at risk of or with symptoms suggestive of either condition.

Prolonged use of glucocorticoids 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.

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

Visual disturbance

Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.

Corticosteroids may increase or decrease motility and number of spermatozoa. Diabetes may be aggravated, necessitating a higher insulin dosage. Latent diabetes mellitus may be precipitated.

Menstrual irregularities may occur, and this possibility should be mentioned to female patients.

Rare instances of anaphylactoid reactions have occurred in patients receiving corticosteroids, especially when a patient has a history of drug allergies.

Aspirin should be used cautiously in conjunction with corticosteroids in patients with hypoprothrombinaemia.

Withdrawal

Drug-induced secondary adrenocortical insufficiency may result from too rapid a withdrawal of corticosteroids and may be minimised 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, corticosteroid therapy should be reinstated. If the patient is receiving steroids already, the dosage may have to be increased. Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently (see section 4.5).

Stopping corticosteroid after prolonged therapy may cause withdrawal symptoms, including fever, myalgia, arthralgia and malaise. In patients who have received more than physiological doses of systemic corticosteroids (approximately 30 mg hydrocortisone) for greater than three weeks, withdrawal should not be abrupt. How dose reduction should be carried out depends largely on whether the disease is likely to relapse as the dose of systemic corticosteroids is reduced. Clinical assessment of disease activity may be needed during withdrawal. If the disease is unlikely to relapse on withdrawal of systemic corticosteroids but there is uncertainty about hypothalamic-pituitary adrenal (HPA) suppression, the dose of systemic corticosteroid may be reduced rapidly to physiological doses. Once a daily dose of 30 mg hydrocortisone is reached, dose reduction should be slower to allow the HPA-axis to recover.

Abrupt withdrawal of systemic corticosteroid treatment, which has continued up to three weeks, is appropriate if it is considered that the disease is unlikely to relapse. Abrupt withdrawal of doses of up to 160 mg daily of hydrocortisone for three weeks is unlikely to lead to clinically relevant HPA-axis suppression, in the majority of patients. In the following patient groups, gradual withdrawal of systemic corticosteroid therapy should be considered even after courses lasting three weeks or less:

• patients who have had repeated courses of systemic corticosteroids, particularly if taken for greater than three weeks;

• when a short course has been prescribed within one year of cessation of long term therapy (months or years);

• patients who may have reasons for adrenocortical insufficiency other than exogenous corticosteroid therapy;

• patients receiving doses of systemic corticosteroid greater than 160 mg hydrocortisone;

• patients repeatedly taking doses in the evening.

Paediatric population

Corticosteroids cause growth retardation in infancy, childhood and adolescence; this may be irreversible. Treatment should be limited to the minimum dosage for the shortest possible time in order to minimise suppression of the hypothalamo-pituitary-adrenal axis and growth retardation (see section 4.2). Growth and development of infants and children on prolonged corticosteroid therapy should be carefully monitored.

Hypertrophic cardiomyopathy was reported after administration of hydrocortisone to prematurely born infants, therefore appropriate diagnostic evaluation and monitoring of cardiac function and structure should be performed.

Use in the elderly

The common adverse effects of systemic corticosteroids may be associated with more serious consequences in old age, especially osteoporosis, hypertension, hypokalaemia, diabetes, susceptibility to infection and thinning of the skin. Close clinical supervision is required to avoid life threatening reactions (see section 4.2).

Hydrocortisone Tablets contains lactose monohydrate.

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.

Hydrocortisone interactions listed below have been reported in pharmacological doses of corticosteroids and may not occur at replacement therapy doses of corticosteroids.

Aspirin should be used cautiously in conjuction with corticosteroids in hypoprothrombinaemia. There is an increased risk of gastro-intestinal bleeding and ulceration when corticosteroids are given with aspirin and NSAIDs, although topical NSAIDs do not generally interact with corticosteroids. The renal clearance of salicylates is increased by corticosteroids and steroid withdrawal may result in salicylate intoxication.

Corticosteroids reduce plasma concentrations of salicylate and such an interaction may occur with pharmacological doses of glucocorticoids.

Phenytoin, ephedrine, rifabutin, carbamazepine, barbiturates (e.g. phenobarbital), rifampicin, primidone, sympathomimetics, aminoglutethimide, St John's wort and less potent inducers such as the antiretroviral medicinal products efavirenz and nevirapine may enhance the metabolic clearance of coticosteroids, resulting in decreased blood levels and lessened physiological activity, thus requiring adjustment in corticosteroid dosage.

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

Ketoconazole alone can inhibit adrenal corticosteroid synthesis and may cause adrenal insufficiency during corticosteroid withdraw (see section 4.4).

The desired actions of hypoglycaemic drugs (including insulin), antihypertensives and diuretics are antagonised by corticosteroids. Glucocorticosteroids are necessay for free water clearance by thekidneys. When corticosteroids are administered concomitantly with potassium-depleting diuretics (e.g. acetazolamide, loop diuretics, thiazides, carbenoxolone), patients should be observed closely for development of hypokalaemia.

Moreover, corticosteroids may affect the nitroblue tetrazolium test for bacterial infaction and produce false negative results.

Corticosteroids antagonise the hypotensive effects of beta-blockers, alpha- blockers, calcium channel blockers, clonidine, diazoxide, methyldopa, moxonidine, nitrates, nitroprusside, hydralazine, minoxidil, adrenergic neurone blockers, ACE inhibitors and angiotensin II receptor antagonists.

Corticosteroids increase risk of hypokalaemia when given with cardiac glycosides, e.g. digoxin, theophylline and beta₂ sympathomimetics e.g. bambuterol, fenoterol, formoterol, ritodrine, salbutamol, salmeterol and terbutaline. The toxicity of cardiac glycosides e.g. digoxin, is increased if hypokalaemia occurs.

There is an increased risk of hypokalaemia when corticosteroids are given with amphotericin. Concomitant use of amphotericin with corticosteroids should be avoided unless amphotericin is needed to control reactions.

The effect of corticosteroids may be reduced for 3-4 days after interaction with mifepristone.

The plasma concentration of corticosteroids is increased by oral contraceptives containing oestrogens and dosage adjustments may be required if oral contraceptives are added to or withdrawn from a stable dosage regimen. Interactions of combined oral contraceptives may also apply to combined contraceptive patches. In the case of hormone replacement therapy, low doses are unlikely to induce interactions. The plasma concentration of corticosteroids may possibly be increased by ritonavir.

Corticosteroids reduce absorption of calcium salts.

Potent CYP 3A4 inhibitors such as ketoconazole, itraconazole, posaconazole, voriconazole, telithromycin, clarithromycin, ritonavir and grapefruit juice can inhibit the metabolism of hydrocortisone and thus increase blood levels. During long-term prophylactic treatment with any of the antibiotics, adjustment of the hydrocortisone dosage should be considered.

The metabolism of corticosteroids can be inhibited by erythromycin, although not when small amounts of erythromycin are used topically.

Corticosteroids antagonise hypoglycaemic effect of antidiabetics.

There's an increased risk of haematological toxicity when corticosteroids are given with methotrexate.

Corticosteroids may inhibit the growth promoting effect of somatropin..

High doses of corticosteroids impair immune response to vaccines, avoid concomitant use with live vaccines.

Corticosteroids possibly reduce the effects of sodium benzoate and sodium phenyl butyrate.

Co-treatment with CYP3A inhibitors, including cobicistat-containing products, is expected to increase the risk of systemic side-effects. The combination should be avoided unless the benefit outweighs the increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid effects.

Pregnancy

The ability of corticosteroids to cross the placenta varies between individual drugs; however, hydrocortisone readily crosses the placenta.

Administration of corticosteroids to pregnant animals can cause abnormalities of fetal development including cleft palate, intra-uterine growth retardation and effects on brain growth and development.

There is no evidence that corticosteroids result in an increased incidence of congenital abnormalities, such as cleft palate / lip in man. However, when administered for prolonged periods or repeatedly during pregnancy, corticosteroids may increase the risk of intra-uterine growth retardation. Pregnant patients should be monitored closely if they develop fluid retention or preeclampsia. Hypoadrenalism may, in theory, occur in the neonate following prenatal exposure to corticosteroids but it is usually resolved spontaneously following birth and is rarely clinically important. As with all drugs, corticosteroids should only be prescribed when the benefits to the mother and child outweigh the risks. When corticosteroids are essential however, patients with normal pregnancies may be treated as though they were in the non-gravid states.

Breast-feeding

Corticosteroids are excreted in breast milk, although no data are available for hydrocortisone.

Infants of mothers taking high doses of systemic corticosteroids for prolonged periods may have a degree of adrenal suppression. Mothers taking pharmacological doses of corticosteroids should be advised not to breast-feed. Maternal treatment should be carefully documented in the infant's medical records to assist in follow up.

Fertility

Patients with adrenal insufficiency have been shown to have reduced parity, which is most likely due to the underlying disease, but there is no indication that hydrocortisone in doses for replacement therapy will affect fertility.

Hydrocortisone has minor influence on the ability to drive and use machines.

Hydrocortisone may cause fatigue, vertigo, visual field loss and muscle wasting and weakness. If affected, patients should not drive or operate machinery (see section 4.8).

The incidence of predictable undesirable effects, including hypothalamic-pituitary-adrenal suppression correlates with the relative potency of the drug, dosage, timing of administration and the duration of treatment (see section 4.4).

Undesirable effects are especially likely to occur at treatment onset or at dose increase.

The undesirable effects are listed below by organ class and the following frequency convention:

Very common: (≥ 1/10)

Common: (≥ 1/100 to <1/10)

Uncommon: (≥ 1/1,000 to <1/100)

Rare: (≥ 1/10,000 to <1/1,000)

Very rare: (<1/10,000)

Not known – cannot be estimated from the available data.

The following side effects may be associated with the long-term systemic use of corticosteroids.

(a) Increased susceptibility and severity of infections with suppression of clinical symptoms and signs, opportunistic infections and recurrence of dormant tuberculosis (see section 4.4), activation of fungal and viral infections including herpes

(b) Reactions are common and may occur in both adults and children. In adults, the frequency of severe reactions have been estimated to be 5-6%. Psychological effects have been reported on withdrawal of corticosteroids.

Paediatric population

Growth suppression in infancy, childhood and adolescence, increased intracranial pressure with papilloedema in children (pseudotumour cerebri), usually after treatment withdrawal.

Withdrawal symptoms:

Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death (see section 4.4). A withdrawal syndrome may also occur including fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store

Reports of acute toxicity and/or deaths following glucocorticoids overdose are rare. No antidote is available.

Symptoms

Overdosage may cause nausea and vomiting, sodium and water retention, hyperglycaemia and occasional gastrointestinal bleeding.

Management

Treatment is probably not indicated for reactions due to chronic poisoning unless the patient has a condition that would render him unusually susceptible to ill effects from corticosteroids. In this case, symptomatic treatment should be instituted as necessary although cimetidine (200-400 mg by slow intravenous injection every 6 hours) or ranitidine (50 mg by slow intravenous injection every 6 hours) may be administered to prevent gastrointestinal bleeding.

Anaphylactic and hypersensitivity reactions may be treated with adrenaline, positive-pressure artificial respiration and arninophylline. The patient should be kept warm and quiet.

The biological half-life of hydrocortisone is about 100 minutes.

Pharmacotherapeutic group: Systemic Hormonal Preparations (excluding sex hormones and insulins); Corticosteroids for Systemic Use; Plain; Hydrocortisone

ATC code: H02AB09

Pharmacodynamic effects

Hydrocortisone is a glucocorticoid. Glucocorticoids are adrenocortical steroids, both naturally-occurring and synthetic, which are readily absorbed from the gastro-intestinal tract.

Hydrocortisone is believed to be the principal corticosteroid secreted by the adrenal cortex. Naturally-occurring glucocorticoids (hydrocortisone and cortisol), 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.

Absorption

Hydrocortisone given by mouth is readily absorbed from the gastrointestinal tract.

Distribution

90% or more of the drug is reversibly bound to protein. The binding is accounted for by two protein fractions. One, corticosteroid- binding globulin is a glycoprotein; the other is albumin.

Biotransformation

Hydrocortisone is metabolised in the liver and most body tissues to hydrogenated and degraded forms, such as tetrahydrocortisone and tetrahydrocortisol.

Elimination

Metabolites are excreted in the urine, mainly conjugated as glucuronides, together with a very small proportion of unchanged hydrocortisone. Half-life of Hydrocortisone is about 1.5 hours. Hydrocortisone (cortisol) is a lipophilic drug that is eliminated completely via metabolism with a low clearance and accordingly low intestinal and hepatic extraction ratios.

Hydrocortisone is eliminated completely by metabolism by 11ß HSD type 1 and type 2 enzymes and CYP 3A4 in the liver and in peripheral tissue. CYP 3A4 is involved in the clearance of cortisol by the formation of 6β -hydroxycortisol which is excreted in urine. The transport of cortisol across membranes is expected to be mediated mainly by passive diffusion and therefore renal and biliary clearances are negligible.

Special populations

Renal impairment

A small amount of cortisol is excreted in the urine unchanged (<0.5% of the daily production), meaning that cortisol is eliminated completely by metabolism. Since severe renal impairment may affect medicinal products completely eliminated via metabolism, dose adjustment may be needed.

Hepatic impairment

No study has been performed in patients with hepatic impairment, however data in the literature for hydrocortisone support that no dose adjustment is required in mild to moderate hepatic impairment. In case of severe hepatic impairment, the functional liver mass decreases and thus the metabolising capacity for hydrocortisone. This may require dose individualisation.

Paediatric population

No pharmacokinetic data are available in children or adolescents.

Administration of corticosteroids to pregnant animals can cause abnormalities of foetal development including cleft palate, intra-uterine growth retardation and effects on brain growth and development.

Starch pregelatinised

Lactose monohydrate

Microcrystalline cellulose

Povidone

Sodium starch glycolate, type A

Talc

Silica colloidal anhydrous

Magnesium stearate.

Not applicable

24 months

Store in the original blister in order to protect from light.

This medicinal product does not require any special temperature storage conditions.

The tablets are packed in opaque white PVC/PVDC/PVC or PVC/PCTFE/PE-EVOH-PE/PVC blister strip, sealed with aluminium foil.

The blister strips are packed in cartons of 30 tablets.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.