It is okay to abruptly stop steroids in resolving septic shock

Kristine A. Sobolewski , Alison Brophy Yekaterina Opsha et el published a retrospective cohort study comparing abrupt withdrawal versus taper of hydrocortisone in resolving septic shock patients.

BACKGROUND

Severe sepsis and septic shock remains one of the most common diagnosis as well as cause of death in intensive care units around the world.

Hydrocortisone has been shown to quicker resolution of shock as well as time of discharge from ICU along with fewer blood transfusions when used in patients with septic shock.

Current surviving sepsis guidelines recommend not using hydrocortisone routinely  if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, then they recommend using hydrocortisone intravenously.

However, there are no comparative studies that support tapering verses abrupt cessation of steroids and inconsistency remains in medical practice with the withdrawal of steroids.

STUDY

Retrospective cohort study of adult patients with septic shock at a single, 600-bed community teaching hospital. 

PATIENTS

Presumed septic shock adult patients on at least 1 vasopressor who were started on hydrocortisone.   Abrupt withdrawal was defined as patients who received a minimum 200 mg of intravenous steroid with cessation without any dose reduction or change in administration time intervals. Tapered withdrawal was defined as patients who received a minimum of 200 mg of intravenous hydrocortisone for  >7 days and underwent subsequent dose reduction.   46 patients were included in the abrupt withdrawal analysis and 41 patients in the gradual taper analysis.

Following were excluded

  1. Predisposing factors for adrenal insufficiency were suspected
  2. History of Addison’s disease,
  3. Duration of high dose steroid therapy that was > 7 days prior to taper or abrupt withdrawal,
  4. Patients who were abruptly withdrawn or tapered while vasopressors still active 
  5. Withdrawal of care or death occurred prior to cessation of steroids
  6. Taper was < 48 h,
  7. No evidence of suspected infection 
  8. if intravenous corticosteroids were documented as administered prior to the initiation of vasopressors.

PRIMARY  ENDPOINT

If  hemodynamic stability occurred  within 72 h following the last administration of steroids.  Hemodynamic instability was defined as  reinitiation of vasopressor therapy.

RESULTS

At baseline, there were no significant differences between the groups with respect to age, gender and sequential organ failure assessment (SOFA) scores. The tapered population had a higher percentage of comorbidities.

Patients who were gradually tapered off steroids experienced a significantly greater incidence of hemodynamic instability, with vasopressor reinitiation occurring in 7 out of the 41 patients (17%) compared to 1 out of 46 (2%) patients in the abrupt withdrawal group, RR 0.85 (95% CI 0.730.98; p = 0.024) .

Patients in the taper group had higher mean glucose values during post hydrocortisone study period (125.1 mg/dL abrupt vs. 150.8 mg/dL taper; p = < 0.001).

LIMITATIONS

  1. Single center
  2. Retrospective study
  3. Small sample size
  4. Did not control or match for comorbidities.

BOTTOMLINE

This study provides a framework for a randomized trial, comparing abrupt versus tapering of steroids in septic shock. However,  this study showed that abrupt withdrawal of steroids in patients receiving 7 days or less of steroid therapy with resolving shock did not cause hemodynamic instability.

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