Steroid Discontinuation Practices in Distributive Shock

Introduction: The efficacy of corticosteroids in septic shock management is supported by landmark trials, demonstrating faster shock reversal and reduced mechanical ventilation duration. Current evidence recommends intravenous (IV) corticosteroids for adults requiring ongoing vasopressor therapy. However, optimal initiation, duration, and discontinuation strategies remain unclear. Previous studies employed varied cessation methods, including abrupt discontinuation and tapering. Limited data compares the effects of these strategies on clinical outcomes. This study aims to evaluate the impact of tapering in comparison to abrupt discontinuation on recovery outcomes, adverse effects, and vasopressor reinitiation to identify the optimal discontinuation strategy.


Methods: This single-center, retrospective chart review included adults admitted between October 2023 and October 2024 with septic shock who received 150-300 mg/day of IV hydrocortisone, at least one vasopressor and antibiotics for ≥48 hours. Patients with non-septic etiologies, Cardiothoracic Intensive Care Unit (CTICU) admissions, hydrocortisone < 48 hours, ongoing vasopressor support at steroid discontinuation, or withdrawal of care were excluded. The primary outcome was hemodynamic instability. Secondary outcomes included hypertension requiring pharmacologic intervention, hyperglycemia, ICU length of stay (LOS), and timing of steroid administration relative to vasopressor therapy.


Results: Ninety patients met inclusion criteria (abrupt group n=54; taper group n=36). Hemodynamic instability occurred in 29.4% (abrupt) vs. 25% (taper), with no significant difference (p=0.631). Hyperglycemia requiring insulin occurred less frequently with abrupt discontinuation (13.0% vs. 33.3%, p=0.018). No significant differences were observed in ICU LOS (10.7 vs. 13.4 days, p=0.217) or hypertensive events (0 vs. 2.8%, p=0.400).


Conclusions: Abrupt discontinuation of corticosteroids after septic shock resolution was not associated with increased hemodynamic instability and was linked to significantly lower rates of hyperglycemia. These findings suggest tapering may not provide additional benefit and support consideration of simplified steroid discontinuation to reduce adverse effects without compromising stability.