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        Pharmacological principles guiding prolonged glucocorticoid treatment in ARDS

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        Meduri2020_Article_PharmacologicalPrinciplesGuidi.pdf (PDF, 2Mb)
        Author
        Meduri, Gianfranco Umberto
        Annane, Dijillali
        Confalonieri, Marco
        Chrousos, George P
        Rochwerg, Bram
        Busby, Amanda
        Ruaro, Barbara
        Meibohm, Bernd
        Attention
        2299/23855
        Abstract
        Current literature addressing the pharmacological principles guiding glucocorticoid (GC) administration in ARDS is scant. This paucity of information may have led to the heterogeneity of treatment protocols and misinterpretation of available findings. GCs are agonist compounds that bind to the GC receptor (GR) producing a pharmacological response. Clinical efficacy depends on the magnitude and duration of exposure to GR. We updated the meta-analysis of randomized trials investigating GC treatment in ARDS, focusing on treatment protocols and response. We synthesized the current literature on the role of the GR in GC therapy including genomic and non-genomic effects, and integrated current clinical pharmacology knowledge of various GCs, including hydrocortisone, methylprednisolone and dexamethasone. This review addresses the role dosage, timing of initiation, mode of administration, duration, and tapering play in achieving optimal response to GC therapy in ARDS. Based on RCTs’ findings, GC plasma concentration–time profiles, and pharmacodynamic studies, optimal results are most likely achievable with early intervention, an initial bolus dose to achieve close to maximal GRα saturation, followed by a continuous infusion to maintain high levels of response throughout the treatment period. In addition, patients receiving similar GC doses may experience substantial between-patient variability in plasma concentrations affecting clinical response. GC should be dose-adjusted and administered for a duration targeting clinical and laboratory improvement, followed by dose-tapering to achieve gradual recovery of the suppressed hypothalamic–pituitary–adrenal (HPA) axis. These findings have practical clinical relevance. Future RCTs should consider these pharmacological principles in the study design and interpretation of findings.
        Publication date
        2020-11-04
        Published in
        Intensive Care Medicine
        Published version
        https://doi.org/10.1007/s00134-020-06289-8
        Other links
        http://hdl.handle.net/2299/23855
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