When to consider adding stress dose steroids in shock and what is the recommended dose?

From the Guidelines

Stress dose steroids should be considered in patients with shock who have known adrenal insufficiency, those at risk for adrenal insufficiency (chronic steroid use), or those with vasopressor-refractory septic shock, with a recommended regimen of hydrocortisone 50-100 mg intravenously every 6-8 hours, or as a continuous infusion of 200-300 mg over 24 hours, as suggested by the latest guidelines 1. The decision to add stress dose steroids in the setting of shock should be based on the patient's response to fluid resuscitation and vasopressor therapy, as well as their underlying risk factors for adrenal insufficiency.

• Key considerations include:
  • Known adrenal insufficiency
  • Chronic steroid use
  • Vasopressor-refractory septic shock
• The recommended dose and duration of treatment should be individualized based on the patient's clinical response and underlying condition, with a general recommendation of hydrocortisone <400 mg/day for at least 3 days at full dose, or longer 1.
• Potential benefits of stress dose steroids include restoring vascular tone, enhancing catecholamine sensitivity, and reducing inflammatory cytokines, which can help stabilize blood pressure and potentially reduce vasopressor requirements.
• However, potential side effects such as hyperglycemia, increased infection risk, and impaired wound healing should be carefully monitored, with blood glucose monitoring essential during treatment 1.
• Ideally, a random cortisol level should be checked before starting steroids if the clinical situation allows, but treatment should not be delayed in unstable patients 1.

From the FDA Drug Label

In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated.

The addition of stress dose steroids should be considered in the setting of shock, as shock can be considered an unusual stress.

• The dose is not specified in the provided drug labels, but it is implied that a rapidly acting corticosteroid should be used.
• Increased dosage of corticosteroids is indicated before, during, and after the stressful situation, but the exact dose is not provided 2, 3.

From the Research

Consideration of Stress Dose Steroids in Shock

The addition of stress dose steroids in the setting of shock should be considered in patients with septic shock who require vasopressors to maintain mean artery pressure ≥65 mmHg, despite adequate fluid resuscitation 4.

Dosing of Stress Dose Steroids

• The suggested dose of intravenous hydrocortisone is 200-300 mg/day for 7 days 4.
• A study comparing low-dose hydrocortisone (50 mg every 6 hours) and high-dose hydrocortisone (100 mg every 8 hours) found that high-dose steroids were associated with shock reversal, although this was not confirmed in the propensity score matched analysis 5.
• Another study found that hydrocortisone compared with placebo was not associated with reduced mortality for patients with septic shock, with a marginal relative risk for 90-day mortality of 0.93 (95% confidence interval [CI], 0.82 to 1.04; P=0.22) 6.

Comparison of Hydrocortisone and Methylprednisolone

• Studies have compared the effects of hydrocortisone and methylprednisolone in patients with septic shock, with one study finding that the survival rates for patients receiving hydrocortisone were relatively higher compared with those receiving methylprednisolone, but the difference was not significant 4.
• Another study found that the use of hydrocortisone versus methylprednisolone does not appear to affect time to shock reversal in oncology patients with septic shock 7.
• A retrospective cohort study using the MIMIC-IV database found that there was no significant difference in 30-day mortality between adults with septic shock administered methylprednisolone and hydrocortisone 8.