ICU · Pharmacology

Corticosteroids — Glucocorticoid & Mineralocorticoid Effects

Also known as Corticosteroids · Glucocorticoids · Mineralocorticoids · Dexamethasone · Hydrocortisone · Prednisolone · Methylprednisolone · Fludrocortisone · 11-beta-HSD2 · Adrenal suppression · Glucocorticoid receptor · Transactivation / transrepression · Stress-dose steroids · ADRENAL trial · APROCCHSS trial · DEXA-ARDS trial · CAPE COD trial · RECOVERY dexamethasone · CORTICUS trial

Corticosteroids in the ICU — the glucocorticoid vs the mineralocorticoid potency, the molecular mechanism, and the disease-specific evidence. MECHANISM: the lipophilic steroid crosses the cell membrane → binds the cytosolic glucocorticoid receptor (GR, NR3C1) → heat-shock-protein dissociation → nuclear translocation → transactivation (GRE-driven anti-inflammatory genes — I-kB, annexin-A1/lipocortin-1, IL-10) and transrepression (GR monomer blocks NF-kB / AP-1 / STAT → downregulates IL-1, IL-2, IL-6, TNF-a); non-genomic effects at high dose. SPECTRUM: hydrocortisone (GC 1, MC 1, equiv 20 mg, short-acting) — physiological replacement, refractory septic shock, adrenal crisis, thyroid storm; prednisolone (GC 4, MC 0.6, equiv 5 mg) — oral immunosuppression, PJP, asthma/COPD; methylprednisolone (GC 5, MC 0.5, equiv 4 mg) — ARDS, autoimmune pulses, spinal-cord injury; dexamethasone (GC 25-30, MC 0, equiv 0.75 mg, long-acting) — cerebral oedema, COVID-19 (RECOVERY 6 mg), antenatal lung maturation, DEXA-ARDS, bacterial meningitis; fludrocortisone (MC 250) — mineralocorticoid replacement, the APROCCHSS septic-shock adjunct. INDICATIONS: septic shock (ADRENAL — hydrocortisone speeds shock reversal, no mortality benefit; APROCCHSS — hydrocortisone + fludrocortisone reduces mortality in SEVERE shock), ARDS (DEXA-ARDS — dexamethasone 20 mg x5d then 10 mg x5d; Meduri methylprednisolone), CAP (CAPE COD — hydrocortisone 200 mg/day; CAPO/Siemieniuk meta-analysis), thyroid storm (hydrocortisone 100 mg TDS blocks T4-T3), adrenal crisis (hydrocortisone 200 mg/day + fludrocortisone), anaphylaxis (adjunct only), asthma/COPD exacerbation, cerebral oedema (dexamethasone). STRESS-DOSE: hydrocortisone 50 mg q6h or 200 mg/24 h infusion in vasopressor-dependent shock; perioperative 100 mg at induction. ADVERSE: hyperglycaemia, immunosuppression, GI bleed, critical-illness myopathy (especially + NMBA), psychiatric effects, osteoporosis, and HPA-axis adrenal suppression after more than 2 weeks of more than 7.5 mg prednisolone equivalent — MUST taper.

Checked against its sources on 2 Sept 2026