What is the recommended dosing regimen for methylprednisolone (corticosteroid) in the treatment of Acute Respiratory Distress Syndrome (ARDS), comparing 40mg twice daily (BD) versus 80mg once daily (OD)?

Methylprednisolone Dosing in ARDS

For early ARDS (≤7 days from onset), methylprednisolone 1 mg/kg/day administered as 40mg twice daily is recommended over 80mg once daily due to better tissue penetration and sustained anti-inflammatory effects. 1

Dosing Recommendations Based on ARDS Stage

Early ARDS (≤7 days from onset)

• Methylprednisolone 1 mg/kg/day with slow tapering over 6-14 days is the recommended regimen 1
• Divided dosing (e.g., 40mg twice daily) is preferred over once-daily dosing (80mg) due to:
  • Greater lung tissue penetration 1
  • Longer residence time in lung tissue 1
  • More consistent anti-inflammatory effect throughout the day 1

Late Persistent ARDS (after day 6 of onset)

• For patients with unresolving ARDS, a higher dose of methylprednisolone (2 mg/kg/day) is recommended 1, 2
• Slow tapering over 13 days is essential to prevent inflammatory rebound 1

Clinical Benefits of Methylprednisolone in ARDS

• Early initiation (within 72 hours) when fibroproliferation is still developing shows better response to lower doses 1
• Treatment is associated with:
  • Reduction in systemic inflammation markers 1
  • Decreased duration of mechanical ventilation by approximately 7 days 1, 3
  • Probable reduction in hospital mortality by 7-11% 1, 3
  • Improved PaO₂/FiO₂ ratios 4

Important Administration Considerations

• Abrupt discontinuation should be avoided as it may lead to deterioration from reconstituted inflammatory response 1
• Regular infection surveillance is essential as glucocorticoid treatment can blunt febrile response 1
• Patients should simultaneously receive lung-protective ventilation strategies (6 ml/kg predicted body weight) per ARDS Network protocol 1

Contraindications and Cautions

• Methylprednisolone should not be used in ARDS secondary to influenza, unless there is another clinical indication 5
• Early steroid therapy in ARDS should not be confused with high-dose pulse steroids, which have not shown benefit 1
• Patients with multiple myeloma or other immunocompromised states require special consideration 5

Potential Adverse Effects

• Hyperglycemia may occur, especially within 36 hours following initial treatment 1
• Potential complications include gastrointestinal bleeding and nosocomial infections 1
• Despite these concerns, meta-analyses suggest methylprednisolone is not associated with increased rates of adverse events in ARDS patients 3

Monitoring During Treatment

• Regular blood glucose monitoring, especially in the first 36 hours 1
• Vigilant infection surveillance throughout treatment course 1
• Monitoring of ventilation parameters and oxygenation indices 4
• Assessment for postextubation stridor, which may be less common with steroid treatment 4