What trial examines the tapering of stress-dose corticosteroids (steroids) in the setting of septic shock?

From the Guidelines

The most recent and highest quality study, the Surviving Sepsis Campaign guidelines 1, suggests tapering hydrocortisone when vasopressors are no longer required in patients with septic shock. The guidelines recommend administering hydrocortisone 200 mg/day as a continuous infusion or in divided doses for the duration of shock, then discontinuing without tapering once vasopressors are no longer needed 1. Some key points to consider when tapering stress dose steroids in septic shock include:

• Tapering is generally unnecessary for short-term stress dose steroids (less than 7-10 days) as the hypothalamic-pituitary-adrenal axis suppression is minimal 1.
• For patients who were on chronic steroids before developing septic shock or who required a prolonged course of stress dose steroids, a gradual taper is recommended to avoid adrenal insufficiency upon discontinuation 1.
• The use of continuous flow when administering hydrocortisone is also recommended (grade 2D) 1. It's worth noting that the ADRENAL trial, which investigated hydrocortisone at a dose of 200 mg daily given as a continuous infusion for 7 days or until ICU discharge, without a tapering schedule, showed that hydrocortisone accelerated shock resolution and reduced time on mechanical ventilation but did not significantly improve 90-day mortality compared to placebo, however, this trial does not specifically address the tapering of stress dose steroids 1. In clinical practice, the decision to taper stress dose steroids should be individualized based on the patient's response to treatment and their underlying medical conditions, with the goal of minimizing the risk of adrenal insufficiency and other potential complications 1.

From the Research

Tapering of Stress Dose Steroids in Septic Shock

• The use of stress-dose steroids in septic shock is a topic of ongoing research, with various studies investigating their effects on patient outcomes 2, 3, 4, 5, 6.
• One study found that a 7-day treatment with low doses of hydrocortisone and fludrocortisone significantly reduced the risk of death in patients with septic shock and relative adrenal insufficiency 2.
• Another study suggested that intravenous hydrocortisone should be started immediately after a corticotropin test, at a dose of 200-300 mg per day, and continued at full doses for 7 days if adrenal insufficiency is confirmed 3.
• The tapering of stress-dose steroids in septic shock is not explicitly addressed in the provided studies, but one study mentions that steroids were discontinued after cortisol values were obtained and relative adrenal insufficiency was ruled out, only to be reinitiated later if necessary 6.
• The use of fludrocortisone in addition to hydrocortisone has been explored in some studies, with mixed results 2, 5.
• Overall, the evidence suggests that stress-dose steroids can be beneficial in septic shock, but the optimal dosing and tapering strategy remains unclear and may depend on individual patient factors 2, 3, 4, 5, 6.

Key Findings

• Low-dose steroids may reduce mortality in septic shock patients 2, 4.
• The use of fludrocortisone in addition to hydrocortisone may be beneficial in certain cases 2, 5.
• Adrenal function in critically ill patients is a dynamic process, and repeated cortisol testing may be necessary to guide steroid therapy 6.

Study Limitations

• The provided studies have varying sample sizes, populations, and methodologies, which may limit their generalizability and comparability 2, 3, 4, 5, 6.
• Further research is needed to fully understand the effects of stress-dose steroids in septic shock and to develop evidence-based guidelines for their use 2, 3, 4, 5, 6.