Hydrocortisone: Wikis


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From Wikipedia, the free encyclopedia

Systematic (IUPAC) name
CAS number 50-23-7
ATC code H02AB09 (and others)
PubChem 5754
ChemSpider 5551
Chemical data
Formula C21H30O5 
Mol. mass 362.460
SMILES eMolecules & PubChem
Therapeutic considerations
Pregnancy cat. C
Legal status Rx Only (U.S.) (excluding 1-2% strength topical)
Routes Oral tablets, intravenously, topical
 Yes check.svgY(what is this?)  (verify)

Cortisol is a corticosteroid hormone or glucocorticoid produced by zona fasciculata of the adrenal cortex, which is a part of the adrenal gland.[1] It is usually referred to as the "stress hormone" as it is involved in response to stress and anxiety, controlled by corticotropin-releasing hormone (CRH). It's primary function is to increase blood sugar and stores of sugar in the liver as glycogen, and also suppresses the immune system. Various synthetic forms of cortisol are used to treat a variety of different illnesses. The most well-known of these is a natural metabolic intermediary of cortisol called hydrocortisone. When first introduced as a treatment for rheumatoid arthritis, hydrocortisone was referred to as Compound E.



The amount of cortisol hormone present in the blood undergoes diurnal variation, with the highest levels present in the early morning, and the lowest levels present around midnight, or 3–5 hours after the onset of sleep. Information about the light/dark cycle is transmitted from the retina to the paired suprachiasmatic nuclei in the hypothalamus. The pattern is not present at birth (estimates of when it starts vary from two weeks to 9 months).[2]

Changed patterns of serum cortisol levels have been observed in connection with abnormal ACTH levels, clinical depression, psychological stress, and such physiological stressors as hypoglycemia, illness, fever, trauma, surgery, fear, pain, physical exertion or extremes of temperature. Cortisol levels may also be different for people with autism or Asperger's syndrome.[3]

There is also significant individual variation, although a given person tends to have consistent rhythms.


See also Therapeutic uses of glucocorticoids

In normal release, cortisol (like other glucocorticoid agents) has widespread actions which help restore homeostasis after stress. (These normal endogenous functions are the basis for the physiological consequences of chronic stress - prolonged cortisol secretion.) It has been proposed that its primary function is to inversely mobilize the immune system to fight potassium-depleting diarrhea diseases.[4]

Cortisol counteracts insulin, contributing to hyperglycemia by stimulus of hepatic gluconeogenesis[5] and inhibition of the peripheral utilization of glucose[5] by decreasing the translocation of glucose transporters to the cell membrane,[6] specially GLUT4[7]. However cortisol increases glycogen synthesis (glycogenesis) in the liver.[8]
In rats, loss of collagen from skin, caused by cortisol, is ten times greater than loss from any other tissue.[9][10] Cortisol (as opticortinol) probably inversely inhibits IgA precursor cells in the intestines of calves.[11] Cortisol also inhibits IgA in serum, as it does IgM, but not IgE.[12]
Gastric secretion
Cortisol stimulates gastric acid secretion.[13] Gastric acid secretion would increase loss of potassium into the stomach during diarrhea as well as acid loss. Cortisol's only direct effect on the hydrogen ion excretion of the kidneys is to stimulate excretion of ammonium ion by inactivation of renal glutaminase enzyme.[14] Net chloride secretion in the intestines is inversely decreased by cortisol in vitro (methylprednisolone).[15]
Cortisol inhibits loss of sodium from small intestines of mammals.[16] However, sodium depletion does not affect cortisol,[17] so cortisol is not used to regulate serum sodium. Cortisol's purpose may originally have been centered around moving sodium because cortisol is used to stimulate sodium inward for fresh water fish and outward for salt-water fish.[18]
Sodium load augments the intense potassium excretion by cortisol, and corticosterone is comparable to cortisol in this case.[19] In order for potassium to move out of the cell, cortisol moves in an equal number of sodium ions.[20] It can be seen that this should make pH regulation much easier, unlike the normal potassium deficiency situation in which about 2 sodium ions move in for each 3 potassium ions that move out, which is closer to the deoxycorticosterone effect. Nevertheless, cortisol consistently causes alkalosis of the serum, while in a deficiency pH does not change. Perhaps this may be for the purpose of bringing serum pH to a value most optimum for some of the immune enzymes during infection in those times when cortisol declines. Potassium is also blocked from loss in the kidneys directly somewhat by decline of cortisol (9 alpha fluorohydrocortisone).[21]
Cortisol also acts as an anti-diuretic hormone. Half the intestinal diuresis is so controlled.[16] Kidney diuresis is also controlled by cortisol in dogs. The decline in water excretion upon decline of cortisol (dexamethasone) in dogs is probably due to inverse stimulation of antidiuretic hormone (ADH or arginine vasopressin), the inverse stimulation of which is not overridden by water loading.[22] Humans also use this mechanism[23] and other different animal mechanisms operate in the same direction.
It is probable that increasing copper availability for immune purposes is the reason many copper enzymes are stimulated to an extent which is often 50% of their total potential by cortisol.[24] This includes lysyl oxidase, an enzyme which is used to cross link collagen and elastin.[25] Particularly valuable for immunity is the stimulation of superoxide dismutase by cortisol[26] since this copper enzyme is almost certainly used by the body to permit superoxide to poison bacteria. Cortisol causes an inverse four- or fivefold decrease of metallothionein, a copper storage protein, in mice[27] (however rodents do not synthesize cortisol themselves). This may be to furnish more copper for ceruloplasmin synthesis or release of free copper. Cortisol has an opposite effect on alpha aminoisobuteric acid than on the other amino acids.[28] If alpha aminoisobuteric acid is used to transport copper through the cell wall, this anomaly would possibly be explained.
Immune system
Cortisol can weaken the activity of the immune system. Cortisol prevents proliferation of T-cells by rendering the interleukin-2 producer T-cells unresponsive to interleukin-1 (IL-1), and unable to produce the T-cell growth factor.[29] Cortisol also has a negative feedback effect on interleukin-1[30]. IL-1 must be especially useful in combating some diseases; however, endotoxin bacteria have gained an advantage by forcing the hypothalamus to increase cortisol levels via forcing secretion of CRH hormone, thus antagonizing IL-1 in this case. The suppressor cells are not affected by GRMF,[31] so that the effective set point for the immune cells may be even higher than the set point for physiological processes. It reflects leukocyte redistribution to lymph nodes, bone marrow, and skin. Acute administration of corticosterone (the endogenous Type I and Type II receptor agonist), or RU28362 (a specific Type II receptor agonist), to adrenalectomized animals induced changes in leukocyte distribution. Natural killer cells are not affected by cortisol.[32]
Bone metabolism
It lowers bone formation thus favoring development of osteoporosis in the long term. Cortisol moves potassium out of cells in exchange for an equal number of sodium ions as mentioned above.[33] This can cause a major problem with the hyperkalemia of metabolic shock from surgery. Cortisol reduces calcium absorption in the intestine.[34]
It cooperates with epinephrine (adrenaline) to create memories of short-term emotional events; this is the proposed mechanism for storage of flash bulb memories, and may originate as a means to remember what to avoid in the future. However, long-term exposure to cortisol results in damage to cells in the hippocampus.[35] This damage results in impaired learning. The desirability of inhibiting activity during infection is no doubt the reason why cortisol is responsible for creating euphoria.[36] The desirability of not disturbing tissues weakened by infection or of not cutting off their blood supply could explain the inhibition of pain widely observed for cortisol.
Additional effects
  • It inhibits the secretion of corticotropin-releasing hormone (CRH), resulting in feedback inhibition of ACTH (Adrenocorticotropic hormone or corticotropin) secretion. Some researchers believe that this normal feedback system may become dysregulated when animals are exposed to chronic stress.
  • It allows for the kidneys to produce hypotonic urine.
  • It shuts down the reproductive system, resulting in an increase for the chance of miscarriage and, in some cases, temporary infertility. Fertility returns after cortisol levels are reduced back to normal levels [37].
  • It has anti-inflammatory effects by reducing histamine secretion and stabilizing lysosomal membranes. The stabilization of lysosomal membranes prevents their rupture, thereby preventing damage to healthy tissues.
  • In addition to the effects caused by cortisol binding to the glucocorticoid receptor, because of its molecular similarity to aldosterone, it also binds to the mineralocorticoid receptor. Aldosterone and cortisol have similar affinity for the mineralocorticoid receptor however, glucocorticoids circulate at roughly 100 times the level of mineralocorticoids. An enzyme exists in mineralocorticoid target tissues to prevent overstimulation by glucocorticoids and allow selective mineralocorticoid action. This enzyme, 11-beta hydroxysteroid dehydrogenase type II (Protein:HSD11B2), catalyzes the deactivation of glucocorticoids to 11-dehydro metabolites.


Most serum cortisol, all but about 4%, is bound to proteins including corticosteroid binding globulin (CBG), and serum albumin. Only free cortisol is available to receptors.


The primary control of cortisol is the pituitary gland peptide, adrenocorticotropic hormone (ACTH). ACTH probably controls cortisol by controlling movement of calcium into the cortisol secreting target cells.[38]. ACTH is in turn controlled by the hypothalamic peptide, corticotropin releasing hormone (CRH), which is under nervous control. CRH acts synergistically with arginine vasopressin, angiotensin II, and epinephrine [39]. When activated macrophages start to secrete interleukin-1 (IL-1), which synergistically with CRH increases ACTH,[30] T-cells also secrete glucosteroid response modifying factor (GRMF or GAF) as well as IL-1, both of which increase the amount of cortisol required to inhibit almost all the immune cells [31]. Thus immune cells take over their own regulation, but at a higher cortisol set point. Even so, the rise of cortisol in diarrheic calves is minimal over healthy calves and drops below with time.[40] The cells do not lose all of the fight or flight override because of interleukin-1's synergism with CRH. Cortisol even has a negative feedback effect on interleukin-1 [41] which must be especially useful against those diseases which gain an advantage by forcing the hypothalamus to secrete too much CRH, such as the endotoxin bacteria..The suppressor immune cells are not affected by GRMF,[31] so that the effective set point for the immune cells may be even higher than the set point for physiological processes. GRMF (called GAF in this reference) primarily affects the liver rather than the kidneys for some physiological processes [42].

A high potassium media, which stimulates aldosterone secretion in vitro, also stimulates cortisol secretion from the fasciculata zone of dog adrenals [43] unlike corticosterone, upon which potassium has no effect [44]. Potassium loading increases ACTH and cortisol in people also [45]. This is no doubt the reason why a potassium deficiency causes cortisol to decline (as just mentioned) and why a potassium deficiency causes a decrease in conversion of 11deoxycortisol to cortisol [46]. This probably contributes to the pain in rheumatoid arthritis since cell potassium is always low in that disease [47]

Factors affecting cortisol levels

Factors generally reducing cortisol levels
  • Magnesium supplementation decreases serum cortisol levels after aerobic exercise,[48][49] but not in resistance training.[50]
  • Omega 3 fatty acids, in a dose dependent manner (but not significantly),[51] can lower cortisol release influenced by mental stress[52] by suppressing the synthesis of interleukin-1 and 6 and enhance the synthesis of interleukin-2, where the former promote higher CRH release. Omega 6 fatty acids, on the other hand, acts inversely on interleukin synthesis.[citation needed]
  • Music therapy can reduce cortisol levels in certain situations.[53]
  • Massage therapy can reduce cortisol.[54]
  • Laughing and the experience of humour can lower cortisol levels.[55]
  • One study by a Japanese cosmetics company has asserted that makeup reduces cortisol levels in a mental stress situation.[56]
  • Soy derived Phosphatidylserine interacts with cortisol but the right dosage is still unclear.[57][58]
  • Vitamin C may slightly blunt cortisol release in response to a mental stressor.[59]
  • Black tea may speed up recovery from a high cortisol condition.[60][61]
Factors generally increasing cortisol levels
  • Caffeine may increase cortisol levels.[62]
  • Sleep deprivation increases cortisol levels.[63]
  • Intense (high VO2 max) or prolonged physical exercise stimulate cortisol release in order to increase gluconeogenesis and maintain blood glucose.[64] Proper nutrition[65] and high-level conditioning[66] can help stabilize cortisol release.
  • Val/Val variation of the BDNF gene in men, and the Val/Met variation in women is associated with increased salivary cortisol in a stressful situation.[67]
  • Hypoestrogenism and melatonin supplementation increases cortisol levels in postmenopausal women.[68]
  • Burnout is associated with higher cortisol levels.[69]
  • Severe trauma or stress events can elevate cortisol levels in the blood for prolonged periods.[70]
  • Subcutaneous adipose tissue regenerates cortisol from cortisone.[71]
  • Anorexia nervosa increases cortisol levels.[72]
  • The serotonin receptor gene 5HTR2C is associated with increased cortisol production in men.[73]
  • Some formulations of combined oral contraceptive pills increase cortisol levels in young women who perform whole-body resistance exercise training.[74]
  • Commuting increases cortisol levels, related to the length of the trip, the amount of effort involved and the predictability of the trip[75]

Diseases and disorders

  • Hypercortisolism: Excessive levels of cortisol in the blood.

The relationship between cortisol and ACTH, and some consequent conditions, are as follows:

Plasma ACTH
Plasma Cortisol Primary hypercortisolism (Cushing's syndrome) Secondary hypercortisolism (pituitary or ectopic tumor, Cushing's disease, pseudo-Cushing's syndrome)
Secondary hypocortisolism (pituitary tumor, Sheehan's syndrome) Primary hypocortisolism (Addison's disease, Nelson's syndrome)


Hydrocortisone is the pharmaceutical term for cortisol used for oral administration, intravenous injection, or topical application. It is used as an immunosuppressive drug, given by injection in the treatment of severe allergic reactions such as anaphylaxis and angioedema, in place of prednisolone in patients who need steroid treatment but cannot take oral medication, and peri-operatively in patients on long-term steroid treatment to prevent an Addisonian crisis. It may be used topically for allergic rashes, eczema, psoriasis and certain other inflammatory skin conditions. It may also be injected into inflamed joints resulting from diseases such as gout.

Compared to prednisolone, hydrocortisone is about 1/4 the strength for the anti-inflammatory effect, while dexamethasone is about 40 times as strong as hydrocortisone. For side effects, see corticosteroid and prednisolone.

Hydrocortisone creams and ointments are available without prescription in strengths ranging from 0.05% to 2.5%, depending on local regulations, with stronger forms available with prescriptions only. Covering the skin after application increases the absorption and effect. Such enhancement is sometimes prescribed, but otherwise should be avoided to prevent over-dosing and systemic impacts.

Advertising for the dietary supplement CortiSlim originally (and falsely) claimed that it contributed to weight loss by blocking cortisol. The manufacturer was fined $1.2 million by the Federal Trade Commission in 2007 for false advertising, and no longer claims in their marketing that CortiSlim is a cortisol antagonist.[76]



Steroidogenesis, showing cortisol at right.

Cortisol is synthesized from cholesterol. The synthesis takes place in the zona fasciculata of the cortex of the adrenal glands. (The name cortisol comes from cortex.) While the adrenal cortex also produces aldosterone (in the zona glomerulosa) and some sex hormones (in the zona reticularis), cortisol is its main secretion. The medulla of the adrenal gland lies under the cortex and mainly secretes the catecholamines, adrenaline (epinephrine) and noradrenaline (norepinephrine) under sympathetic stimulation (more epinephrine is produced than norepinephrine, in a ratio 4:1).

The synthesis of cortisol in the adrenal gland is stimulated by the anterior lobe of the pituitary gland with adrenocorticotropic hormone (ACTH); production of ACTH is in turn stimulated by corticotropin-releasing hormone (CRH), released by the hypothalamus. ACTH increases the concentration of cholesterol in the inner mitochondrial membrane (via regulation of STAR (steroidogenic acute regulatory) protein). ACTH also stimulates the main rate-limiting step in cortisol synthesis where cholesterol is converted to pregnenolone, catalyzed by Cytochrome P450SCC (side chain cleavage enzyme).[77]


Cortisol is metabolized by the 11-beta hydroxysteroid dehydrogenase system (11-beta HSD), which consists of two enzymes: 11-beta HSD1 and 11-beta HSD2.

  • 11-beta HSD1 utilizes the cofactor NADPH to convert biologically inert cortisone to biologically active cortisol.
  • 11-beta HSD2 utilizes the cofactor NAD+ to convert cortisol to cortisone.

Overall the net effect is that 11-beta HSD1 serves to increase the local concentrations of biologically active cortisol in a given tissue, while 11-beta HSD2 serves to decrease the local concentrations of biologically active cortisol.

Cortisol is also metabolized into 5-alpha tetrahydrocortisol (5-alpha THF) and 5-beta tetrahydrocortisol (5-beta THF), reactions for which 5-alpha reductase and 5-beta reductase are the rate-limiting factors, respectively. 5-beta reductase is also the rate-limiting factor in the conversion of cortisone to tetrahydrocortisone (THE).

An alteration in 11-beta HSD1 has been suggested to play a role in the pathogenesis of obesity, hypertension, and insulin resistance, sometimes referred to the metabolic syndrome.[citation needed]

An alteration in 11-beta HSD2 has been implicated in essential hypertension and is known to lead to the syndrome of apparent mineralocorticoid excess (SAME).[citation needed]

See also

Additional images


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