Response to Letter by Wong and Poon
We are very pleased to see that much thought and attention is being given to this area of treatment, and we would like to provide the following as a response.
Our first response is that for the past 20 years, we have been administering hydrocortisone at 1200 mg/d to patients with aneurysmal subarachnoid hemorrhage under our protocol and have not experienced any problems with avascular necrosis.
When we first commenced our clinical trials, in order to anticipate any side-effects, the blood hydrocortisone concentration was measured in this dosage. The peak concentration obtained during administrating 1200 mg/d of hydrocortisone to subarachnoid hemorrhage patients were equal to about 30% of the peak level of the healthy volunteers. This is believed to be due to dilution with the infusion fluids because patients with subarachnoid hemorrhage are infused with over 3000 mL fluid.
In addition to this, we also examined the effects of administering dexamethasone, methylpredonisone and hydrocortisone in rats and found there were very little effects on bone density by hydrocortisone, which seems to relate to the elimination half life (unpublished data).
We have also used fludrocortisone in the past, and already reported similar effects as with hydrocortisone.1 In our country, however, fludrocortisone is not readily available in fluid formulation, making it difficult to procure; therefore, hydrocortisone is used in our protocol at 1200 mg/d.
We hope this helps to show that we were very cognizant of the effects of hydrocortisone and that through the respective tests explained above, we were assured that it is safe enough to use hydrocortisone with our protocol.