When should corticosteroids (CS) be administered to patients?

When to Administer Corticosteroids

Corticosteroids should be administered in specific critical illness scenarios where they reduce mortality and morbidity: septic shock requiring vasopressors, early moderate-to-severe ARDS, and community-acquired pneumonia requiring hospitalization. 1

Critical Care Indications

Septic Shock

• Administer hydrocortisone 200 mg/day (as continuous infusion or divided doses every 6 hours) in patients with vasopressor-dependent septic shock who have responded poorly to fluids and vasopressor agents 1, 2
• Continuous infusion is preferred over bolus dosing to avoid significant glucose fluctuations 3
• Treatment should be initiated as early as possible (within 3 hours) to reduce time to vasopressor discontinuation 3
• Continue for ≥7 days, then taper gradually rather than stopping abruptly 1, 2
• Do NOT use the ACTH stimulation test to identify which septic shock patients should receive corticosteroids 2

Acute Respiratory Distress Syndrome (ARDS)

• Use corticosteroids in patients with early moderate-to-severe ARDS (PaO₂/FiO₂ <200 and within 14 days of onset) 1
• Methylprednisolone 1 mg/kg/day for ≥14 days is recommended 2
• Early initiation (<72 hours) shows better response than late initiation (≥7 days), with faster disease resolution and shorter time to unassisted breathing 1
• Treatment reduces duration of mechanical ventilation by approximately 7 days and reduces hospital mortality by 7-11% 1

Community-Acquired Pneumonia (CAP)

• Administer corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent in hospitalized patients with CAP 1
• Treatment reduces hospital stay (by ~3 days), need for mechanical ventilation (RR 0.45), and prevents ARDS (RR 0.24) 1
• Benefit is most pronounced in patients with severe rather than mild pneumonia 1

Adrenal Insufficiency and Crisis

Chronic Replacement Therapy

• Primary adrenal insufficiency requires hydrocortisone 15-25 mg daily (or prednisone 3-5 mg daily) plus fludrocortisone 0.05-0.3 mg daily 4
• Secondary/glucocorticoid-induced adrenal insufficiency requires glucocorticoids alone (no mineralocorticoid) 4
• Administer the largest portion in the morning upon awakening (before 9 am) to mimic physiologic cortisol rhythm 5

Adrenal Crisis (Emergency)

• Immediately administer hydrocortisone 100 mg IV bolus, followed by continuous infusion of 200 mg/24 hours (or 50 mg IV every 6 hours) 3, 6, 4
• IV administration results in immediate bioavailability with peak levels at 10-20 minutes and clinical effects within one hour 3
• IM administration is acceptable if IV access unavailable, with therapeutic levels reached within 11±5 minutes 3
• For major stress/surgery: 100 mg IV at induction, then 200 mg/24 hours continuous infusion throughout perioperative period 3

Stress Dosing

• All patients with adrenal insufficiency should be instructed to increase glucocorticoids during acute illness 4
• Patients should be prescribed injectable hydrocortisone 100 mg IM for emergency use 4
• Continuous IV infusion of 200 mg hydrocortisone over 24 hours (preceded by 50-100 mg bolus) is optimal for maintaining cortisol concentrations during major stress 7

Conditions Where Corticosteroids Are NOT Recommended

Influenza

• Do NOT use corticosteroids in adults with influenza (OR of dying 3.06 with corticosteroid use) 1

Anaphylaxis

• Corticosteroids are NOT helpful for treating acute anaphylaxis due to slow onset of anti-inflammatory action (4-6 hours), though they may help prevent biphasic reactions 3

Important Administration Considerations

Route and Timing

• IV administration is preferred for emergency situations due to immediate bioavailability 3, 6
• Administer IV doses over 30 seconds (100 mg) to 10 minutes (500 mg or more) 6
• Rapid administration of large IV doses (>0.5 g in <10 minutes) can cause cardiac arrhythmias and arrest 8

Duration and Tapering

• High-dose therapy should be continued only until patient stabilizes, usually not beyond 48-72 hours 6, 8
• After long-term therapy, withdraw gradually rather than abruptly 6, 8
• Consider reinstituting treatment with recurrence of sepsis signs, hypotension, or worsening oxygenation 2

Common Pitfalls to Avoid

• Do NOT use dexamethasone to treat critical illness-related corticosteroid insufficiency (lacks mineralocorticoid activity needed in primary adrenal insufficiency) 3, 2
• Do NOT stop corticosteroids abruptly after prolonged use—risk of adrenal crisis 6, 8
• Do NOT delay administration in suspected adrenal crisis—delays can be fatal 3
• Do NOT use high-dose, short-course corticosteroids (>30 mg/kg/day methylprednisolone equivalent)—provides no benefit and may be harmful 9