Tip of the hat to Raj Patel for inspiring this clinical question.
26F h/o lupus is brought into resus for positive sepsis screen at triage. Patient c/o pleuritic CP, SOB, headache, n/v starting today. Vitals are 101.3 140 74/55 24 96%. Patient is on prednisone for lupus. In addition initiating your work-up for infectious source, IVF and antibiotics, you are concerned about adrenal insufficiency. What are the merits and pitfalls of using the following corticosteroids?
1) Hydrocortisone is the physiologic equivalent of endogenous cortisol. It has both glucocorticoid and mineralocorticoid-receptor activity. It’s the latter that makes it useful in treating adrenal insufficiency (AI) as deficiencies in both cortisol and aldosterone lead to a greater hypotensive effect. Therefore, hydrocortisone given at moderate-doses (ie 100mg) is the ED treatment of choice.
2) Solu-Medrol (methylprednisolone) is a glucocorticoid we typically give for it’s anti-inflammatory effects. It has minimal mineralocorticoid activity, so you lose out on the benefit of using hydrocortisone.
3) Apparently using dexamethasone as to not interfere with cortisol stimulation testing (w/ ACTH) is a bit of a myth. Dex cause “immediate” and “prolonged” suppression of the HPA axis and is therefore not recommended in sepsis with suspected AI.
4) Fludrocortisone is a strong mineralocorticoid. Some people use it as an adjunct to hydrocortisone. There isn’t enough good data to prove these patients benefit from this addition. Not considered a necessary ED medication for AI at this time.
Some of this information may seem controversial (it did to me). It comes from an extensive international collaboration of intensivists. The reference is:
Marik PE, Pastores SM, Annane D, Meduri GU, Sprung CL, Arlt W, Keh D, Briegel J, Beishuizen A, Dimopoulou I, Tsagarakis S, Singer M, Chrousos GP, Zaloga G, Bokhari F, Vogeser M; American College of Critical Care Medicine. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008 Jun;36(6):1937-49.