EXPERT ANALYSIS FROM THE CCC47

SAN ANTONIO (FRONTLINE MEDICAL NEWS) – When corticosteroids are used for septic shock, the dose should be low to moderate, the timing should be early, and the duration should be at least 3 days, said a speaker at the Critical Care Congress sponsored by the Society for Critical Care.

Dosing, timing, and duration are “three critical questions” critical care specialists face that are answered by the new critical illness–related corticosteroid insufficiency (CIRCI) guidelines, continued Stephen M. Pastores, MD , a cochair of the task force that developed guidelines for the diagnosis and management of CIRCI in critically ill patients.

The recently published guidelines come in two parts. The first takes into account the most current evidence on the use of corticosteroids in disorders that most clinicians associate with CIRCI, including sepsis/septic shock, acute respiratory distress syndrome, and major trauma ( Crit Care Med. 2017 Dec;45[12]:2078-88 ). Part two of the guidelines, published separately, covers other syndromes, such as influenza, meningitis, burns, and other conditions that at least 80% of the task force members agreed were associated with CIRCI ( Crit Care Med. 2018 Jan;46[1]:146-148 ).

During his presentation, Dr. Pastores limited his remarks to discussion of sepsis and septic shock with corticosteroids. He cautioned that, despite careful deliberations by the panel, the level of evidence behind some of the recommendations was “low to moderate and never high” and that not all task force members agreed with all recommendations.

“There were a lot of back and forth disagreements behind these recommendations,” said Dr. Pastores, who is the director of the critical care medicine fellowship training and research programs at Memorial Sloan Kettering Cancer Center, New York. “We only required 80% of the panelists to agree that these were the recommendations and statements that we were going to go by.”

The guidelines recommend against the use of corticosteroids in adult patients who have sepsis without shock, Dr. Pastores noted.

In contrast, the guidelines do suggest using corticosteroids for hospitalized adults patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy.

In an analysis of available data from randomized clinical trials including patients with septic shock, corticosteroids significantly reduced 28-day mortality when compared with placebo, Dr. Pastores said.

That survival benefit seems to be dependent on several factors: dose of the corticosteroids (hydrocortisone less than 400 mg/day), longer duration (at least 3 or more days), and severity of sepsis. “The more severe the sepsis, the more septic shock the patient was in, the more likely the corticosteroids were likely to help those patients,” Dr. Pastores explained.

Accordingly, the guidelines further suggest using long-course, low-dose corticosteroid treatment, namely intravenous hydrocortisone at no more than 400 mg/day for at least 3 days.

The expert panel specifically recommended hydrocortisone as the corticosteroid of choice in this setting, according to Dr. Pastores. That recommendation was based in part on a recent systematic review and meta-analysis showing that hydrocortisone, given as a bolus or an infusion, was more likely than placebo or methylprednisolone to result in shock reversal.

Dr. Pastores reported disclosures related to Theravance Biopharma, Bayer HealthCare Pharmaceuticals, Spectral Diagnostics, and Asahi-Kasei.

chestphysiciannews@chestnet.org

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