Corticosteroid regimens in sepsis

Bram Rochwerg, MD, is an intensivist, researcher, and associate professor of medicine at McMaster University. His main focus of research includes resuscitation medicine and intravenous fluid use in sepsis. He works with many international organizations supporting their guideline development projects, including the Canadian Critical Care Society and the Society of Critical Care Medicine.

When do you start corticosteroids in patients with sepsis? Which drug do you choose and how do you decide when to stop?

Bram Rochwerg, MD: These are great questions and I feel passionate about the evidence that informs corticosteroid use in sepsis. We’ve done a number of systematic reviews, meta-analyses, and clinical practice guidelines. My general sense is that there’s fairly resounding evidence to suggest benefit of corticosteroids for patients in sepsis.

Long we have believed that the main role of corticosteroids was for relative adrenal insufficiency. That’s not why I use corticosteroids in sepsis. We recognize that sepsis is related to dysfunctional immune response. A lot of end organ dysfunction is related to dysfunctional immune response. When I think about using corticosteroids in sepsis, I am not using it for relative adrenal insufficiency but I’m using it to help regulate a dysregulated immune response, help knock down some of that inflammatory cytokine release and inflammatory cell activation. I have a very early threshold based on what I think is good data of using corticosteroids in definitely anybody with septic shock, even to the point that I will use corticosteroids in patients with sepsis and organ failure, even if they don’t quite yet have shock.

When it comes to the right molecule, dose, and schedule, there’s a lot of heterogeneity in what folks use. We’ve done the meta-analyses and subgroup analyses within those that suggest that there’s no real difference when it comes to which molecule you use, what dose you use, whether you taper or not. I’m not sure it really matters. I think you could use hydrocortisone, you could use methylprednisolone, you could use prednisone. When it comes to sepsis, I tend to use hydrocortisone 100 to 200 mg/d, usually split up into every 6 hours (q6h) or qh dosing [editor’s note: continuous infusion]. And I think the only reason I picked that is because that’s what the majority of the studies looking at corticosteroids in sepsis have used, but I don’t think that there’s any magic to those regimens.

When it comes to stopping them, if it’s somebody in septic shock, I usually wait until their shock is resolved. Then, most often I’ll just stop steroids without a taper. And if it’s somebody with organ dysfunction, I’ll usually treat for 48 to 72 hours. Then, if they’re moving in the right direction, I’ll stop. Whereas if they’re going on pressors or doing worse, I might extend the course of therapy.