What are the guidelines for using corticosteroids (CS) in various medical conditions?

Corticosteroid Use Guidelines Across Medical Conditions

COVID-19

For non-severe COVID-19, systemic corticosteroids should NOT be used, as they may increase 28-day mortality risk. 1

• Corticosteroids are conditionally recommended AGAINST in patients with non-severe COVID-19 (those without increased respiratory rate, respiratory distress, or hypoxemia) 1
• The evidence shows systemic corticosteroids may increase mortality risk in this population (low certainty evidence) 1

Important exceptions where corticosteroids should be given:

• Patients already on chronic corticosteroids for other conditions (COPD, autoimmune disease) should continue them 1
• If clinical condition worsens (increased respiratory rate, respiratory distress, hypoxemia), immediately initiate corticosteroids 1
• Pregnant patients at risk of preterm birth (24-34 weeks) may benefit from antenatal corticosteroids after shared decision-making 1

Sepsis and Septic Shock

For septic shock not responsive to fluid resuscitation and moderate-to-high dose vasopressors, use IV hydrocortisone 200 mg/day for at least 3 days. 2

• Administer as either divided doses or continuous infusion 2
• Continue at full dose for minimum 3 days, then taper when vasopressors are no longer required rather than stopping abruptly 2
• Do NOT use corticosteroids for sepsis without shock—provides no benefit 1, 2
• The HYPRESS trial showed no difference in progression to septic shock or mortality with hydrocortisone versus placebo in sepsis without shock 2

Common pitfall: Do not use the ACTH stimulation test to identify which patients should receive hydrocortisone—it is not recommended 2

Community-Acquired Pneumonia (CAP)

For hospitalized patients with CAP, use corticosteroids at <400 mg IV hydrocortisone equivalent daily (preferably 200 mg/day) for 5-7 days. 1, 2, 3

• Benefits include: reduced hospital stay (risk difference -2.96 days), decreased need for mechanical ventilation (RR 0.45), prevention of ARDS (RR 0.24), and mortality reduction (RR 0.67) 1
• The effect is most pronounced in severe rather than mild pneumonia 1
• Risk of hyperglycemia increases (RR 1.49) but other complications are not significantly increased 1

Acute Respiratory Distress Syndrome (ARDS)

For early moderate-to-severe ARDS, use IV methylprednisolone 1 mg/kg/day. 2

• Methylprednisolone is preferred over hydrocortisone due to greater lung tissue penetration and longer residence time 2
• This applies specifically to early moderate-to-severe ARDS, not mild cases 2

Influenza

Do NOT use corticosteroids in adults with influenza—they increase mortality. 1

• Analysis of 13 observational studies showed odds ratio of dying of 3.06 (95% CI 1.58-5.92) against corticosteroids 1
• Corticosteroids also increase risk of superinfection in influenza patients 1

Cardiopulmonary Bypass Surgery

Use corticosteroids in patients undergoing cardiopulmonary bypass surgery. 1

• Reduces mortality (RR 0.84) and atrial fibrillation (RR 0.80) 1
• Methylprednisolone 250 mg IV at anesthesia induction and at onset of CPB is one effective regimen 1
• Dexamethasone 1 mg/kg perioperatively reduces superinfection (RR 0.64), delirium (RR 0.79), and respiratory failure (RR 0.69) 1

Immune Thrombocytopenia (ITP)

For newly diagnosed ITP with platelets <30 × 10⁹/L and asymptomatic or minor bleeding, corticosteroids are conditionally suggested over observation. 1

For platelets ≥30 × 10⁹/L with asymptomatic or minor bleeding, observation is strongly recommended over corticosteroids. 1

• For platelets at the lower end of the ≥30 threshold, elderly patients (>60 years), those on anticoagulants/antiplatelets, or with upcoming procedures, corticosteroids may be appropriate 1
• Use corticosteroids alone rather than rituximab plus corticosteroids for initial therapy 1

Monitoring requirement: Assess for hypertension, hyperglycemia, sleep/mood disturbances, gastric irritation, glaucoma, myopathy, and osteoporosis 1

Allergic Bronchopulmonary Aspergillosis (ABPA)

Use corticosteroids for acute ABPA exacerbations, starting with prednisone ~0.5 mg/kg/day. 1

• Taper based on individual clinical course, not symptoms alone—significant lung damage can occur in asymptomatic patients 1
• Initiate corticosteroids if: increasing serum IgE levels, new/worsening infiltrate on chest X-ray, or worsening spirometry 1

Major Trauma

Do NOT use corticosteroids for major trauma—no mortality benefit and potential harm. 1, 2

• Analysis of 19 trials showed no significant effect on mortality (RR 1.00,95% CI 0.89-1.13) 1, 2
• Two trials in trauma-associated CIRCI showed mixed results, with imprecision preventing clear conclusions 1

Critical Monitoring and Adverse Effects

Monitor all patients on corticosteroids for:

• Hyperglycemia and hypernatremia 2
• Secondary infections (corticosteroids blunt febrile response) 2
• Gastrointestinal bleeding 2
• Psychiatric effects 2
• Osteoporosis risk—consider calcium, vitamin D, bisphosphonates, and weight-bearing exercise 4

Tapering: When discontinuing after prolonged use, taper slowly over 6-14 days to avoid rebound inflammation 2. Abrupt discontinuation can cause clinical deterioration 2.

Infection risk: Dose-dependent increases in serious and opportunistic infections occur with chronic use 5. Implement vaccination and screening strategies before initiating chronic therapy 5.

Drug interactions to monitor:

• Warfarin—monitor coagulation indices frequently 6
• Antidiabetics—adjust doses as corticosteroids increase blood glucose 6
• Strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir)—can decrease corticosteroid metabolism by up to 60%, increasing side effect risk 6
• Hepatic enzyme inducers (phenytoin, rifampin)—may require increased corticosteroid doses 6