Comparative Effectiveness of Less vs. More Frequent Hydrocortisone Dosing in Septic Shock.

Abstract

Objectives: Guidelines recommend hydrocortisone as an adjunctive treatment in septic shock, but the optimal dosing regimen is unknown. A national shortage of hydrocortisone in 2023 prompted a change in institutional practice for hydrocortisone administration from 50 mg every 6 hours to 100 mg every 12 hours in an effort to reduce waste and conserve vials, creating an opportunity to evaluate the comparative effectiveness of these two regimens. The primary efficacy outcome was time to shock resolution, and secondary outcomes evaluated in this study were mortality, renal replacement therapy (RRT), medication costs, and maximum vasopressor dose attained.

Design: Single-center, retrospective cohort study.

Setting: ICUs in a quaternary academic medical center.

Patients: Adult patients admitted to an ICU with septic shock, defined by mean arterial pressure less than 65 mm Hg despite adequate fluid resuscitation and need for vasopressor infusion, who were treated with hydrocortisone for shock between October 24, 2022, and October 12, 2023.

Interventions: Treatment with hydrocortisone 50 mg every 6 hours or 100 mg every 12 hours.

Measurements and main results: One hundred thirty-eight patients were included in this retrospective chart review from October 24, 2022, to October 12, 2023. Data for 61 patients in the 50 mg every 6 hours group and 77 patients in the 100 mg every 12 hours group were collected and analyzed. In adjusted competing risk models, hydrocortisone regimen was not associated with differences in time to shock resolution (sub-hazard ratio [sub-HR] 0.95 [95% CI, 0.59-1.54]), ICU mortality (sub-HR 1.59; 95% CI, 0.89-2.84), in-hospital mortality (1.35; 95% CI, 0.81-2.26), or time to RRT (sub-HR 1.01; 95% CI, 0.45-2.31). In addition, the hydrocortisone dose regimen was not associated with differences in maximum vasopressor dose attained (mean difference in norepinephrine equivalent, 0.16 µg/kg/min; 95% CI, -0.26 to 0.58 µg/kg/min). The less frequent dosing resulted in cost savings of $446.10 (95% CI, 253.95-638.25) per patient treated with the more intensive but less frequent hydrocortisone dosing regimen.

Conclusions: A less frequent hydrocortisone dosing regimen was not associated with differences in time to shock resolution. Studies of the comparative effectiveness of different corticosteroid dosing regimens for septic shock are needed.