Steroid Tapering in Septic Shock
Yes, steroids should be tapered when vasopressors are no longer required, rather than stopped abruptly, to avoid hemodynamic and immunologic rebound effects. 1
Recommended Tapering Approach
The Surviving Sepsis Campaign and SCCM/ESICM guidelines suggest tapering hydrocortisone when vasopressors are discontinued (Grade 2D recommendation). 1, 2 This is based on evidence showing hemodynamic and immunologic rebound effects after abrupt cessation. 1
Specific Tapering Protocol
- Initial treatment duration: Maintain full-dose hydrocortisone (<400 mg/day) for at least 3-5 days before initiating taper 1, 2
- Taper duration: Gradually reduce over 6-14 days 2, 3
- Timing: Begin taper when vasopressors are no longer required 1, 2
Method of Tapering
The evidence shows heterogeneity in tapering methods, with no clear superiority of one approach: 4
- Frequency reduction (most common method - 56.8% of cases) 4
- Dose reduction 4
- Both fixed-duration protocols and clinically-guided regimens have been used 1
Evidence Quality and Nuances
The recommendation for tapering is based on weak evidence (Grade 2D). 1 No direct comparative studies exist between tapering versus abrupt cessation, or between fixed-duration versus clinically-guided regimens. 1
Key Supporting Evidence
- One crossover study demonstrated hemodynamic and immunologic rebound effects after abrupt cessation 1
- Recent observational data (2025) showed patients receiving tapers had increased vasopressor requirements at 24 hours (37.4% vs 21.3%, P=0.004) 4, suggesting potential rebound effects during the taper itself
- The CORTICUS trial used a 6-day taper after 5 days of full-dose therapy 5
Critical Monitoring During Taper
Monitor for the following complications: 2
- Hypernatremia (serum sodium levels) 2
- Hyperglycemia (blood glucose) 1
- Hemodynamic instability (blood pressure, vasopressor requirements) 4
- Shock recurrence 4
Common Pitfalls to Avoid
- Do not use ACTH stimulation testing to guide tapering decisions - it has no role in determining when or how to taper 2
- Avoid abrupt discontinuation - this can lead to deterioration from reconstituted inflammatory response 2
- Be aware that etomidate use prior to hydrocortisone may worsen outcomes 1, 2
- Do not use steroids in sepsis without shock - no benefit demonstrated 1
Alternative Consideration
One study showed no difference in outcomes whether hydrocortisone was used for 3 or 7 days, suggesting optimal duration remains uncertain. 1 However, the consensus recommendation favors tapering over abrupt cessation based on physiologic rationale and limited observational data showing rebound effects. 1, 2