Risk of High Dose Hydrocortisone in Patients With Aneurysmal Subarachnoid Hemorrhage
To the Editor:
We read with great interest the article by Katayama et al.1 In concordance with their previous pilot study,2 the authors showed that hydrocortisone 1200 mg/d prevented excess sodium excretion and urine volume, and achieved the management of hypervolemic protocol with lower sodium and fluid. The rationale for hydrocortisone 1200 mg/d was that it had shorter elimination half-life than fludrocortisone and its mineralocorticoid effect was comparable to the mineralocorticoid effect of fludrocortisone 0.3 mg/d. We congratulated the authors for reporting such a thoughtful study.
We had, however, a concern for the hydrocortisone dosage (equivalent to prednisolone 300 mg/d). One important side-effect of high-dose steroid is avascular necrosis of hip. The estimated incidence is 0.3% to 0.6%3,4 and it can be devastating to the patient. In this clinical setting, we would prefer fludrocortisone at lower dosage as 0.1 to 0.2 mg/d to the abovementioned regimen.
Katayama Y, Haraoka J, Hirabayashi H, Kawamata T, Kawamoto K, Kitahara T, Kojima J, Huroiwa T, Mori T, Moro N, Nagata I, Ogawa A, Ohno K, Seiki Y, Shiokawa Y, Teramoto A, Tominaga T, Yoshimin T. A randomized controlled trial of hydrocortisone against hyponatremia in patients with aneurismal subarachnoid hemorrhage. Stroke. 2007; 38: 2373–2375.
Moro N, Katayama Y, Kojima J, Mori T, Kawamata T. Prophylactic management of excessive natriuresis with hydrocortisone for efficient hypervolemic therapy after subarachnoid hemorrhage. Stroke. 2003; 34: 2807–2811.