Indication of corticosteroids* Dosing regimen and tapering §
1) Septic shock Hydrocortisone at a dose of 200 mg per day as continuous infusion. Should be tapered when vasopressors are no longer required
2) Airway edema Dexamethasone is 0.5-2 mg/kg divided over 4-6 hrs started 24 hours before extubation and continued for 24 hours after extubation
3) Spinal cord injury Methylprednisolone should be initiated within eight hours of injury using an initial bolus of 30 mg/kg by IV for 15 minutes followed 45 minutes later by a continuous infusion of 5.4 mg/kg/hour for 23 hours
4) ARDS loading dose of 1 mg/kg of methyl prsnisolone followed by an infusion of 1 mg/kg/d from day 1 to day 14, then 0.5 mg/kg/d from day 15 to day 21, then 0.25 mg/kg/d from day 22 to day 25, and finally 0.125 mg/kg/d from day 26 to day 28. In the study if the patient was extubated between days 1 and 14, the patient was advanced to day 15 of drug therapy and tapered according to schedule
5) Bacterial meningitis Dexamethasone 0.15 mg/kg q6 h for 2–4 days with the first dose administered 10–20 min before, or at least concomitant with, the first dose of antimicrobial therapy
6) Tuberculous (TB) meningitis Patients with grade II or III disease should receive intravenous treatment of dexamethasone for four weeks (0.4 mg per kilogram per day for the first week, 0.3 mg per kilogram per day for the second week, 0.2 mg per kilogram per day for the third week, and 0.1 mg per kilogram per day for the fourth week) and then oral treatment for four weeks, starting at a total of 4 mg per day and decreasing by 1 mg each week Patients with grade I disease should receive lower dose of intravenous dexamethasone therapy with shorter duration of two weeks (0.3 mg per kilogram per day for the first week and 0.2 mg per kilogram per day for the second week) and then four weeks of oral therapy (0.1 mg per kilogram per day for the third week, then a total of 3 mg per day, decreasing by 1 mg each week)
7) Pneumocystis jirovecii pneumonia Prednisone 40 mg q 12 hrs per os (PO) for 5 days followed by 40 mg q24 hrs PO for 5 days and then 20 mg q24 hrs PO for 11 days
8) Lupus Nephritis IV pulse methylprednisolone of 1 gram per day for 3 days monthly for 6 months, with 0.5-1.5 mg of oral prednisone per kilogram between pulses
9) COPD exacerbations Methyl prednisiolone succinate IV 125 mg every 6 hours for 3 days then 60 mg daily for 4 days then 40 mg daily for 4 days then 20 mg daily for 4 days.
10) Asthma exacerbations 120 to 180 mg/day of prednisone, prednisolone, or methylprednisolone in 3 or 4 divided doses for 48 hours and then 60 to 80 mg/day until peak expiratory flow rate (PEFR) reaches 70% of predicted
11) Brain edema. Dexamethasone with initial dose of 10 mg intravenously or orally, followed by 4 mg every 6 hours Corticosteroids should be tapered within 2 to 3 weeks. This can be done by decreasing the dose by 50% every 4 days
12) Anaphylaxis Prednisone 1 mg/kg up to 50 mg orally or hydrocortisone 1.5-3 mg/kg IV
13) Pulmonary fibrosis Methyl prednisiolone pulse therapy (1000 mg/day for 3 days, 500 mg/day for 2 days, 250 mg/day for 2 days, 125 mg/day for 2 days, and 80 mg/day for 2 days), followed by oral prednisolone (1 mg per kilogram per day, reduced by about 20% each week)
14) Thyroid storm Hydrocortisone 300 mg intravenous loading followed by 100 mg every 8 hours
15) Myxedema Intravenous hydrocortisone should be given at a dosage of 100 mg every eight hours
16) Brain dead patients that are candidates for organ donation Methylprednisolone 15 mg/kg IV every 24 hours
* Many other indications of corticosteroids are not covered like autoimmune hemolytic anemia, prevention and treatment of rejection of transplanted organs, hypercalcemia and many others because their incidence in the ICUs is rare. § There is controversy about dosing and tapering of steroids, so effort has been made to include the best available evidence.
Table 2: Common indications of corticosteroids in ICU