What is the appropriate dosage of corticosteroids (steroids) for Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

For ARDS, methylprednisolone 1 mg/kg/day is the recommended steroid regimen for early ARDS (up to day 7 of onset) and 2 mg/kg/day for late persistent ARDS (after day 6 of onset), followed by slow tapering over 13 days. This recommendation is based on the guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients, which suggest that methylprednisolone be considered in patients with early and late ARDS 1. The task force members believed that the quality of the evidence for the effect of corticosteroids on mortality was moderate, given the serious risk of imprecision related to small numbers of events and confidence intervals that approach no effect.

Some key points to consider when using steroids in ARDS include:

• Starting steroids early in moderate-to-severe ARDS, ideally within the first 14 days of onset
• Monitoring for hyperglycemia, secondary infections, and psychiatric effects during treatment
• Considering adjusting the dose in patients with liver dysfunction or those on medications that affect steroid metabolism
• Avoiding abrupt discontinuation of steroids after prolonged use to prevent adrenal insufficiency
• The benefit of steroids appears greatest when initiated early in the course of ARDS, particularly in patients with severe ARDS, as shown in a recent individual patient data (IPD) analysis of the four largest trials investigating prolonged methylprednisolone treatment in early and late ARDS 1.

It is also important to note that the use of corticosteroids in ARDS has been associated with a significant reduction in markers of systemic inflammation, reduction in the duration of mechanical ventilation, and probable reduction in hospital mortality, as reported in nine trials that investigated prolonged glucocorticoid treatment in ARDS 1.

From the Research

Dosage of Steroids in ARDS

The optimal dosage of steroids for patients with Acute Respiratory Distress Syndrome (ARDS) is not explicitly stated in the provided studies. However, the studies suggest that corticosteroids may be beneficial in reducing mortality and shortening the duration of mechanical ventilation in patients with ARDS.

Key Findings

• A systematic review and meta-analysis of randomized trials found that corticosteroids reduced all-cause mortality and the duration of mechanical ventilation, and increased the number of ventilator-free days in patients with ARDS 2.
• Another study found that methylprednisolone may improve mortality, shorten ventilation times, and increase the number of ventilator-free days in patients with ARDS, but the evidence is controversial 3.
• A randomized controlled trial found that methylprednisolone increased the number of ventilator-free and shock-free days during the first 28 days, but did not support the routine use of methylprednisolone for persistent ARDS 4.
• A systematic review and meta-analysis found that methylprednisolone had a statistically significant effect on mortality and the time of mechanical ventilation in patients with ARDS, but was not associated with increased rates of adverse events 5.

Corticosteroid Regimens

• The studies included different corticosteroid classes and initiated drug administration at different times, as well as used various dosing regimens 2.
• One study suggested that low- to moderate-dose corticosteroids may be beneficial in the treatment of early and late-phase ARDS, but the evidence is controversial 3.
• Another study found that starting methylprednisolone therapy more than two weeks after the onset of ARDS may increase the risk of death 4.

Adverse Effects

• Corticosteroids may increase the risk of hyperglycemia and neuromuscular weakness in patients with ARDS 2, 4.
• Methylprednisolone was not associated with increased rates of adverse events, but was associated with a higher rate of neuromuscular weakness 4, 5.