Daily Literature Update
Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock
Gilchrist HE, Roginski M, Esteves A, et al. Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock. Hosp Pharm. 2025 Jul;:00185787251355438-. doi: 00185787251355438. PMID: 40671936
Study Type: Retrospective cohort study
Population: 276 ICU patients with septic shock receiving 6gt;=24 hours hydrocortisone (Jan 2020 – Dec 2023)
Intervention: Stress dose hydrocortisone therapy with or without tapering
Outcomes: Vasopressor rates post-taper, hospital and ICU mortality, ICU length of stay, mechanical ventilation duration
- 50.4% (139) patients received hydrocortisone taper; median taper duration 2 days (IQR 1 63)
- Tapering mainly by reducing dosing frequency (56.8% of taper patients)
- Higher vasopressor rate at 24h post taper start/discontinuation in taper group (37.4% vs 21.3%, P = .004)
- No significant difference in vasopressor rate at 48h (20.3% vs 12.9%, P = .14)
- Decreased hospital mortality (OR 0.55; 95% CI, 0.33-0.92) and ICU mortality (OR 0.47; 95% CI, 0.27-0.81) in taper group
- Increased ICU length of stay (OR 1.04; 95% CI, 1.02-1.06) and mechanical ventilation duration (OR 1.08; 95% CI, 1.03-1.12) with taper
Context & Related Research
- Systematic review/meta-analysis: Corticosteroids reduce short-term mortality and increase shock reversal but increase hyperglycemia risk (PubMed 38250247)
- Early vs late hydrocortisone: Early use shortens vasopressor duration, no mortality difference (PubMed 34109850)
- Abrupt vs taper discontinuation: Abrupt cessation linked to less vasopressor reinitiation, more hyperglycemia with tapering (PubMed 35927963)
- General corticosteroid risks: Associated with hyperglycemia and neuromuscular weakness; optimal dosing and tapering remains uncertain
Strengths & Limitations
| Strengths | Limitations |
|---|---|
| Large patient cohort (N=276) across 4 years | Retrospective design with potential confounding |
| Detailed evaluation of tapering methods and durations | Lack of randomized control and potential selection bias |
| Multiple clinically relevant outcomes assessed | Variability in tapering protocols limits generalizability |
Clinical Implications & Impact
Pharmacists should recognize the variability in hydrocortisone tapering practices and weigh the short-term hemodynamic risks with longer-term mortality benefits. Given the increased vasopressor need and ICU stay with tapering, careful monitoring and individualized taper strategies are essential. This underscores the need to develop standardized protocols and further prospective research to optimize steroid discontinuation in septic shock management.
Conclusion
Variability in hydrocortisone tapering for septic shock is common; tapering is associated with increased early vasopressor use but decreased hospital and ICU mortality, highlighting the need for further guidelines and research.
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Citations
- Gilchrist HE et al. Hosp Pharm. 2025 Jul;:00185787251355438-. PMID:40671936
- Systematic Review et al. PubMed. 2023; PMID:38250247
- Hydrocortisone Timing Study. PubMed. 2021; PMID:34109850
- Abrupt vs Taper Corticosteroid Study. PubMed. 2022; PMID:35927963
