Thread by @IM_Crit_

ICU Pharmacy pearls:
If u have not heard the news, there is a national shortage of IV hydrocortisone (HC) ...
ashp.org/drug-shortages…
So, if u are like me & use often HC in septic shock, u need to be aware of other options. If HC (Solu-Cortef®) is not available, consider use of

an alternative parenteral corticosteroid: methylprednisolone (MP) (Solu-Medrol®) or dexamethasone (D)

The "problem" w these two drugs is that they have minimal mineralocorticoid activity, so u may need to supplement them w fludrocortisone (FC)

This should not be a totally unknown practice for intensivists, since the "prototype" of positive steroid trials in septic shock, the Annane trial published 20 years ago in JAMA (jamanetwork.com/journals/jama/…) implemented a 7 day course w iv hydrocortisone AND enteral fludrocortisone

Of note:
1. Hydrocortisone has a shorter biological half-life (8-12 h) than methylprednisolone (12-36 h) & dexamethasone (36-72 h)
2. In terms of glucocorticoid equivalency:
100mg of hydrocortisone = 20mg methylprednisolone = 4mg dexamethasone

Considering #1 and #2 👆, reasonable alternative regimen suggestions are:

1. HC 100mg iv q8h = MP 20mg iv q8h (or 30mg iv q12h) (OR: HC 50mg iv q6h = MP 20mg iv q12h)
PLUS
FC 50mcg - 100mcg po q24h
(since MP has some/minimal mineralocorticoid activity)
👇

2. HC 100mg iv q8h = D 6mg iv q12h + FC 100 mcg po q24h (OR: D 12mg iv q24h + FC 100mcg po q24h).
Similarly:
HC 50mg iv q6h = D 4mg iv q12h + FC 100mcg po q24h (OR: D 8mg iv q24h + FC 100mcg po q24h)
(since D has essentially NO clinically significant mineralocorticoid activity)

Thanks for reading!

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