[CK] Stress-dose gluticocorticoid(steroid) [v ] read and sum! (50mcg IVP solucortef vs 125mg solumedrol=for steroid user>5mg pred.)

STRESS DOSE

Solucortef 50mg q6hr !
or
Solumedrol 60-125mg iv q6-8hr !(severe sepsis shock or known prednisone user !)


https://www.uptodate.com/contents/glucocorticoid-therapy-in-septic-shock?topicRef=1613&source=see_link

Summary

●

Random <10 but don't rely on lab test. => just do it if it's indicated in critically ill patient.s 

●"functional" adrenal insufficiency, "relative" adrenal insufficiency,  "critical illness-related corticosteroid insufficiency (CIRCI)." 

=But a clear definition is lacking

●Less severe septic shock: restored by fluid and pressor = corticosteroid therapy does not appear to be beneficial.

●Severe septic shock: sBP <90 with adequate fluid + vasopressor(more than 1 hr, NE >0.5) .=> may need to add 2nd dose or... 

= reduces weaning pressor quicker. => start within 24hours for severe septic shock. 

● ACTH stimulation testing is not clinically useful.

Recommendations

●

Hydrocortisone : 50mg IV Q6HR. (200mg total. could be higher upto 100mg IV Q6HR) 

no fludrocortisone topped on this. (maybe added for sicker one with 50mcg via G-tube qday... for the certain case. but not suggested grade 2C) 

-The risk of superinfection does not appear to be consistently elevated among studies.

-but Na, Glucose retention.

●

●3d ~ 7d. with tapering as guided by the clinical response => decrease dose 50mg -> 25mg and weaning pressor. (After 5 days or 7days full dose and stop) 

Evidence: French Trial, CORTICUS trial
=> Benefit for adequate indication(mortality 28days, morbidity improved)

Empirical Steroid
Hydrocortisone(200mg/day) = prednisone 40mg/day(high dose)
                                              = solumedrol 50mg/day(high dose) but real life? 125mg q8hr. f..k!?




For adrenal crisis prophylaxis in adult patients with known or suspected adrenal insufficiency undergoing major surgery, or with other acute stressors (e.g., major cardiothoracic surgery, Whipple procedure, liver resection, pancreatitis, acute systemic infection, shock).

Intravenous or Intramuscular dosage (hydrocortisone sodium succinate injection)

Adults

Although the manufacturer recommends 200 to 500 mg IV or IM every 2 to 6 hours starting at the beginning of surgical procedure or the onset of the acute physiologic stressor , recommendations developed from the literature and expert opinion suggest lower doses are effective and decrease the risk of adverse effects (e.g., hyperglycemia, immunosuppression). In severe illnesses or major surgeries, one author recommends 100 to 150 mg IV/IM on the day of the procedure; taper to the usual dose over the next 1 to 2 days. Another author recommends 50 mg IV/IM every 6 hours during the medical or surgical stress; then, taper the dose by 50% every day until the usual dose is reached. Although hydrocortisone has historically been the preferred agent, some experts recommend longer acting steroids such as methylprednisolone or dexamethasone. In addition to the supplementation doses, patients who are treated with chronic steroids should also be given their usual dose or equivalent for the acute period; patients receiving the equivalent to prednisone 5 mg/day (i.e., hydrocortisone 20 mg/day) or less do not require additional supplementation.

For adrenal crisis prophylaxis in adult patients with known or suspected adrenal insufficiency and a critical illness (e.g., shock).

Intravenous or Intramuscular dosage (hydrocortisone sodium succinate injection)

Adults

Although the manufacturer recommends 200 to 500 mg IV or IM every 2 to 6 hours starting at the beginning the acute physiologic stressor , recommendations developed from the literature and expert opinion suggest lower doses are effective. In critically ill patients, 50 to 100 mg IV every 6 to 8 hours or 0.18 mg/kg/hour as a continuous IV infusion until the shock is resolved has been recommended; 50 mcg/day of fludrocortisone is also recommended in this situation. Once the shock is resolved, the hydrocortisone can be gradually tapered; follow vital signs and serum sodium concentrations closely. Although, hydrocortisone has historically been the preferred agent, some experts recommend longer acting steroids such as methylprednisolone or dexamethasone. In addition to the supplementation doses, patients who are treated with chronic steroids should also be given their usual dose or equivalent for the acute period; patients receiving the equivalent to prednisone 5 mg/day (i.e., hydrocortisone 20 mg/day) or less do not require additional supplementation.

cf> COPD: Prednisone 40mg qday or Solumedrol 60~125mg iv q6~8hr.(does not make sense! BUT. in usual...) at least solumedrol < 240mg = shorten hospitalization.

Dose – The optimal dose of systemic glucocorticoids for treating a COPD exacerbation is unknown [1,44]. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines advise using the equivalent of prednisone 40 mg once daily for the majority of COPD exacerbations (table 4) [1]. Frequently used regimens range from prednisone 30 to 60 mg, once daily, to methylprednisolone 60 to 125 mg, two to four times daily, depending on the severity of the exacerbation [43,45,46]. A growing body of evidence favors using a moderate, rather than high dose of glucocorticoids, for most patients with an exacerbation of COPD. As an example, a comparative analysis of glucocorticoid dosing examined outcomes of 79,985 patients admitted to the hospital with an exacerbation of COPD, excluding those requiring intensive care [45]. The median glucocorticoid dose administered in the first two days was 60 mg for those on oral therapy and 556 mg for intravenous therapy. The risk of treatment failure was no greater with the lower dose. As this was an observational study and did not include objective measures of airflow limitation, it is possible that less ill patients were more likely to receive oral treatment.

On the other hand, for patients with impending or actual acute respiratory failure due to a COPD exacerbation, many clinicians use an intravenous formulation at a higher dose, such as the equivalent of methylprednisolone 60 mg intravenously, one to four times daily, although outcomes data to guide this practice are limited. In an observational cohort study, among 17,239 patients admitted to an intensive care unit (ICU) with an exacerbation of COPD, a dose of methylprednisolone of 240 mg/day or less, compared with a higher dose (methylprednisolone >240 mg/day), was not associated with a mortality benefit, but was associated with slightly shorter hospital (-0.44 days, 95% CI -0.67 to -0.21) and ICU (-0.31 days; 95% CI -0.46 to -0.16) lengths of stay [47]. Length of mechanical ventilation and need for insulin therapy were also lower in the lower dose group. As this was an observational study, further research is needed to determine the optimal glucocorticoid dose in this setting.

Comparison of systemic corticosteroid preparations

	Equivalent doses (mg)	Anti-inflammatory activity relative to hydrocortisone*	Duration of action (hours)
Glucocorticoids
Short acting
Hydrocortisone (cortisol)	20	1	8 to 12
Cortisone acetate	25	0.8	8 to 12
Intermediate acting
Prednisone	5	4	12 to 36
Prednisolone	5	4	12 to 36
Methylprednisolone	4	5	12 to 36
Triamcinolone	4	5	12 to 36
Long acting
Dexamethasone	0.75	30	36 to 72
Betamethasone	0.6	30	36 to 72
Mineralocorticoids
Fludrocortisone	Not used for an anti-inflammatory effect¶. The typical dose of fludrocortisone for mineralocorticoid replacement is 0.1 to 0.2 mg.		12 to 36

The mineralocorticoid effect of commonly administered glucocorticoids may be estimated as follows:

• When given at replacement doses, triamcinolone, dexamethasone, and betamethasone have no clinically important mineralocorticoid activity.
• 20 mg hydrocortisone and 25 mg of cortisone acetate each provide a mineralocorticoid effect that is approximately equivalent to 0.1 mg fludrocortisone.
• Prednisone or prednisolone given at anti-inflammatory doses ≥50 mg per day provide a mineralocorticoid effect that is approximately equivalent to 0.1 mg of fludrocortisone.

* Equivalent anti-inflammatory dose shown is for oral or intravenous (IV) administration. Relative potency for intra-articular or intramuscular administration may vary considerably.
¶ The anti-inflammatory potency is 10 to 15 times that of hydrocortisone; however, fludrocortisone is not used clinically as an anti-inflammatory agent.

Data from:

1. Schimmer BP, Funder JW. ACTH, Adrenal Steroids, and Pharmacology of the Adrenal Cortex. In: Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 12th ed, Brunton LL, Chabner BA, Knollmann BC (Eds), McGraw-Hill Education 2011.
2. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol 2013, 9:30.

Graphic 64138 Version 20.0

ENDO note>

1. Secondary Adrenal Insufficiency secondary to Chronic Prednisone:
-Plan is to SLOWLY taper patient's prednisone in 2.5 mg increments.  He will not be able to taper off prednisone completely because he has been on prednisone for 15 years.
-Recommend tapering patient's prednisone from 20 mg PO daily to 17.5 mg PO daily (as you have done) for at least 2 weeks (i.e., until seen in Endocrine Clinic).
-We will see patient in endocrinology clinic to further manage steroid taper. If clinically appropriate at that time, we will continue tapering to 15 mg PO daily prednisone for 2 weeks.
--If unable to wean prednisone in 2.5 mg increments, will convert prednisone to hydrocortisone (1 mg prednisone = 4 mg hydrocortisone) and taper from there as this allows for tapering in smaller decrements.
-Will decide in clinic when to do cortisol stimulation test.
-We will continue to follow while patient is inpatient.