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Peer-reviewedCC BY-NC-ND 4.0European Journal of Clinical Pharmacology

Systemic corticosteroids in critical illness: an evidence-based framework for clinical decision-making

  • Yu-Wen Chang1
  • Chun-Fu Chung2
  • Suey-Haur Lee2
  • Meng-Yun Tsai2,3
  • Yu-Ping Chang2,4
  • Cheng-Chih Wu1
  • Kuo-Tung Huang2,5,6
6 affiliations
  1. 1Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
  2. 2Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, 833401 Taiwan
  3. 3Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
  4. 4Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Municipal Fong Shan Hospital–Under the management of Chang Gung Medical Foundation, Kaohsiung, Taiwan
  5. 5Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
  6. 6Chang Gung Respirology Center of Excellence, Taoyuan, Taiwan
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Abstract

Purpose: Systemic corticosteroids are pivotal in managing inflammation-driven critical illnesses, yet bedside translation remains inconsistent. This systematic review establishes an evidence-based framework for clinical decision-making by horizontally synthesizing contemporary evidence across severe community-acquired pneumonia (sCAP), acute respiratory distress syndrome (ARDS), and septic shock.

Methods: A systematic electronic search was conducted across PubMed, EMBASE, and the Cochrane Library up to early 2026. Peer-reviewed randomized controlled trials (RCTs), systematic reviews, and meta-analyses published in English were eligible. Data regarding population characteristics, dosing regimens, initiation timing, duration, and safety profiles were independently extracted and qualitatively synthesized.

Results: Landmark trials define context-dependent efficacy: early hydrocortisone continuous infusion significantly reduces 28-day mortality in sCAP (CAPE COD), while a 10-day dexamethasone regimen improves ventilator-free days and survival in moderate-to-severe ARDS (DEXA-ARDS). In septic shock, early hydrocortisone-fludrocortisone combination accelerates shock resolution and lowers 90-day mortality (APROCCHS). These outcomes align with distinct pharmacological profiles: hydrocortisone provides dual glucocorticoid/mineralocorticoid activity to restore vascular tone, whereas dexamethasone exerts potent transrepression of proinflammatory transcription factors. To mitigate steroid-induced harm, protocolized safety targets are essential, including maintaining blood glucose at 140–180 mg/dL and actively monitoring for secondary infections.

Conclusion: Corticosteroids do not exert a uniform class effect. Bedside success requires personalized, protocolized regimens optimized by scenario-specific timing, dosing, and proactive adverse-event monitoring.

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Cite

BibTeXRIS
BibTeX
@article{chang2026systemic,
  title = {{Systemic corticosteroids in critical illness: an evidence-based framework for clinical decision-making}},
  author = {Yu-Wen Chang and Chun-Fu Chung and Suey-Haur Lee and Meng-Yun Tsai and Yu-Ping Chang and Cheng-Chih Wu and Kuo-Tung Huang},
  journal = {European Journal of Clinical Pharmacology},
  year = {2026},
  month = nov,
  doi = {10.1007/s00228-026-04211-7},
  url = {https://doi.org/10.1007/s00228-026-04211-7},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Systemic corticosteroids in critical illness: an evidence-based framework for clinical decision-making
AU  - Yu-Wen Chang
AU  - Chun-Fu Chung
AU  - Suey-Haur Lee
AU  - Meng-Yun Tsai
AU  - Yu-Ping Chang
AU  - Cheng-Chih Wu
AU  - Kuo-Tung Huang
PY  - 2026
DA  - 2026/11/04
JO  - European Journal of Clinical Pharmacology
DO  - 10.1007/s00228-026-04211-7
UR  - https://doi.org/10.1007/s00228-026-04211-7
AB  - Purpose: Systemic corticosteroids are pivotal in managing inflammation-driven critical illnesses, yet bedside translation remains inconsistent. This systematic review establishes an evidence-based framework for clinical decision-making by horizontally synthesizing contemporary evidence across severe community-acquired pneumonia (sCAP), acute respiratory distress syndrome (ARDS), and septic shock.  Methods: A systematic electronic search was conducted across PubMed, EMBASE, and the Cochrane Library up to early 2026. Peer-reviewed randomized controlled trials (RCTs), systematic reviews, and meta-analyses published in English were eligible. Data regarding population characteristics, dosing regimens, initiation timing, duration, and safety profiles were independently extracted and qualitatively synthesized.  Results: Landmark trials define context-dependent efficacy: early hydrocortisone continuous infusion significantly reduces 28-day mortality in sCAP (CAPE COD), while a 10-day dexamethasone regimen improves ventilator-free days and survival in moderate-to-severe ARDS (DEXA-ARDS). In septic shock, early hydrocortisone-fludrocortisone combination accelerates shock resolution and lowers 90-day mortality (APROCCHS). These outcomes align with distinct pharmacological profiles: hydrocortisone provides dual glucocorticoid/mineralocorticoid activity to restore vascular tone, whereas dexamethasone exerts potent transrepression of proinflammatory transcription factors. To mitigate steroid-induced harm, protocolized safety targets are essential, including maintaining blood glucose at 140–180 mg/dL and actively monitoring for secondary infections.  Conclusion: Corticosteroids do not exert a uniform class effect. Bedside success requires personalized, protocolized regimens optimized by scenario-specific timing, dosing, and proactive adverse-event monitoring.
SN  - 0031-6970
SN  - 1432-1041
ER  -