CEimpact Podcast

The Great Debate of Steroid Use in CAP

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Corticosteroids in the treatment of community-acquired pneumonia (CAP) remain a topic of clinical curiosity and mixed opinions. In this unique episode, two expert guests share opposing perspectives—one advocating for corticosteroid use in CAP and the other urging caution—offering pharmacists a balanced view of the current evidence and practice considerations. Tune in to explore both sides of the debate and walk away with insights to inform your role in collaborative patient care.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Clinical Editor, CEimpact
Lead Editor, Pyrls

GUESTS
Sam Markle, PharmD
Critical Care Pharmacist
Sanford Health

Tristan Houle, PharmD
PGY2 Critical Care Pharmacy Resident
Sanford Health

PRACTICE RESOURCE
Purchase this course to receive the exclusive downloadable practice resource handout to use as a reference guide to the podcast.

CPE REDEMPTION
This course is accredited for continuing pharmacy education! Click the link below that applies to you to take the exam and evaluation:

CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe current evidence supporting and challenging the use of corticosteroids in the treatment of community-acquired pneumonia (CAP).
2. Identify key considerations for pharmacists when evaluating corticosteroid use as adjunctive therapy in CAP.

Rachel Maynard, Sam Markle, and Tristan Houle have no relevant financial relationships to disclose.

0.05 CEU/0.5 Hr
UAN: 0107-0000-26-032-H01-P
Initial release date: 1/5/2026
Expiration date: 1/5/2027
Additional CPE details can be found here.

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SPEAKER_00:

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop it listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning count. Hey CE Impact subscribers, and welcome to the Game Changers Clinical Conversations Podcast. I'm your host, Rachel Maynard, and we've got a really interesting topic and format for our conversation today. So to start with the topic today, we're going to be looking at critical steroid use and community-acquired pneumonia, or CAP, which has been a bit controversial and has led to some strong opinions and some different schools of thought, especially as new studies offer conflicting evidence on the role of steroids in managing CAP. And then in terms of the format for our episode today, we're actually going to be bringing together two voices, so one in favor and one opposed, to explore and debate where steroids fit into that CAP conversation and how we as pharmacists can navigate those clinical gray areas. So I am absolutely thrilled to have Sam Markle and Tristan Hole as our guests for today's episode. So welcome, Sam and Tristan. Thank you so much for joining us today.

SPEAKER_04:

Yes, thank you for having us.

SPEAKER_00:

All right. Really appreciate your time. And uh before we jump in, maybe we can just do some brief intros and have you each share a little bit about yourselves, your current roles, and your practice settings. And I think that will probably tie into why you're interested in this topic about steroids and caps. So Tristan, I'll start out with you. If you want to give a brief intro to yourself.

SPEAKER_04:

Yeah, absolutely. So yeah, my name is Tristan Hoole. I am currently a second-year resident out here in Sanford in Fargo, North Dakota. I am the critical care resident, so I'm in kind of like my second year of more like specialized training. Um so I kind of go hopping around from each of our different ICUs and emergency departments. Um, and I have very large interest in like our infectious disease, sepsus septic shock topics. So that's kind of what brought me along to this topic.

SPEAKER_00:

Absolutely. Yeah, you sound like you're right in the thick of this world and this debate. So great to have you. And Sam, let's hear about you.

SPEAKER_02:

Yeah, absolutely. Well, thanks for having us, Rachel. My name is Sam Markle. I'm currently a critical care pharmacist as well as the assistant residency program director for our PGY2 critical care pharmacy residency here. So I get the privilege of working with Tristan on a day-to-day basis. Um, and I've worked here at Sanford for the last about seven years, practicing in kind of a hospital pharmacy/slash critical care role after completing my training here. So I'm very much passionate about the management of similar to what Tristan mentioned, the critically ill patients who have infectious disease concerns. And as we know, community-acquired pneumonia is extremely common in the population. So we see quite a bit of it. So anything that we can learn to help manage these patients better is ideal.

SPEAKER_00:

Excellent. And you've also then being there in that setting for several years now, have sort of seen how things maybe have evolved over time a bit. And so very interested to hear your perspective too. Excellent. Well, let's go ahead and kick off the conversation. And I think just sort of setting the stage for everyone would be helpful just to get aligned in terms of what community acquired pneumonia is. You know, Sam, you mentioned it's a very common condition, but just maybe for those of us who haven't been in that world for a little bit, you know, what it is and some of the pathophysiology behind it, because I do think that's gonna help tie into this discussion about corticosteroids and CAP and some of that debate. So um, Tristan, would you be able to start off that conversation?

SPEAKER_04:

Yeah, absolutely. So, yeah, our community choir pneumonia, or CAP, as we'll continue to refer to it, um, is gonna be one of our most common and clinically important infections that we see across, you know, multiple settings. So obviously very important to us in like our ICUs in the hospital, as well as lots of antibiotics going out to more of like our retail counterparts. Um, so it is kind of a widespread at its core. Our CAP is just an infection of the lung tissue that kind of develops outside of the hospital or any long-term care facility. So that's where it gets kind of that like community-acquired pneumonia setting, is usually due to either bacteria, viruses, or tape or atypical organisms that end up kind of triggering inflammation deep like in our lungs and our alveoli. Um, some of our more classic culprits for that, our more standard bacteria would be like our strepcoccal pneumonia or haemo influenza. And then we also have viral causes, just like our normal influenza RSVs, and then you can also see some atypical bacteria like our mycoplasma or legionella. So, what kind of leads us to our most kind of important factors is we're obviously going to see this in like our aging populations and gonna be really important somewhere like widespread chronic lung and heart disease patients, diabetes, smoking, um, all of those typical things that you think of. And kind of the pathophysiology of why patients might get up to like where me and Sam are, like in the critical care setting, um, is actually a little bit past just that like standard infection. So when we have those infections, we have those pathogens that are gonna be identified in our lungs. Um, we're gonna have that rapid release of our some of our pro-inflammatory cytokines, we'll have release of like our neutrophils, um, which is gonna kind of lead to that immune cascade. So we'll have neutrophils that end up re releasing like our reactive oxygen species and our proteases with the intent to kill those pathogens, but the also the issue is that it can also injure our like our cells. So our type 1 and 2 alveolar cells, our permanent endothelium can also be injured in this scenario. Um, so that's gonna lead to sort of a breakdown of that alveolar capillary barrier. So, really, that's important for two reasons that can kind of lead to impaired gas exchange and shunting and a lot of edema in the lungs. So that's kind of what progresses us to our acute respiratory distress syndrome, which is going to lead us to need for that mechanical ventilation. But on top of that, with that breakdown barrier, we can also see kind of a systemic effect. So those cytokines can get out into the like into our circulating blood volume, and that's where we're going to see more of that vasodilation, hypotension, organ dysfunction. That's how we get to our sepsis and septic shock. And it's actually that dysregulated inflammation that can be that main driver of progression to like needing ICU care, need that mechanical ventilation, needing those vasopressors in place outside of just like the pathogen load that you get with our community-acquired pneumonia. So, what what steroids, what the goal in this scenario is, is going to be putting something out in front of that to try and stop some of that more like systemic spillover, some more like trying to prevent our mechanical ventilation and need for vasopressors versus and the like obviously our antibiotics are gonna be important for treating that infection, but the main issue, the main thing that brings patients to us is that like systemic spillover. So trying to get in front of that with our glute with our corticosteroids.

SPEAKER_00:

Gotcha. Okay, so it's really trying to just tamp down that inflammatory response that immune system sort of cascade, as you talked about. So using that corticosteroid to tamp down that inflammation. Okay, so yeah, it's it's outside of the any antimicrobial therapy considerations, but focusing on the inflamm inflammatory side of things really. Yes, yep. Okay, okay, great. That's again, really good perspective. And I think it's also helpful to be thinking about the patient population that we're really focused on here. And so, as you mentioned, you're in the ICU, thinking about those ICU patients. And so, Sam, you know, thinking about the role of corticosteroids and maybe how it's evolved over time. Can you give us an overview of what you've seen in practice and and how that landscape has evolved and where the controversy that we have comes from?

SPEAKER_02:

Yeah, Rachel, I think uh anytime you bring up the conversation about steroids in any type of critically ill patient population, there's there's always that gray uh gray area of controversy. Um, and community acquired pneumonia is no exception to that. When we look back historically at the data that we had leading up into the modern day practice, we had a ton of heterogeneity across our studies and our patient populations and our dosing regimens and how we're essentially running these trials. And as a result, when we compile all this patient data together, there was no real great consensus. When you look back at the guidelines that have been published over the course of the last decade or so, we look at the IDSA guidelines as kind of the gold standard for management of these patients with a community-quired pneumonia, and their recommendation generally is that um there's no real benefit to using steroids in these patients. And a lot of this can be traced back to a mate analysis of all of these kind of lower quality studies that were published over the last 10 years. And while they did find that the patients had about one day less of hospital length of stay and one day less of symptoms, there was no major patient-centered outcome difference. And predominantly they're looking at mortality. And as a result, then the Infectious Diseases Society of America said, Yeah, we can't really recommend this for our patients. The critical care societies generally leaned in the direction of give steroids to everyone, and it's probably going to be beneficial. But there was no strong consensus. And it was really not until about the last four or five years where we started to get an accumulation of new evidence to kind of re-e-evaluate this practice. And across these different trials, there have still been some mixed results. But now we're in the the era where the trials are a little bit higher quality, but they're looking at patient populations that are a little more modernized and hopefully will help to give us a better idea and better decision on whether we should use steroids in these patients.

SPEAKER_00:

Do you think some of that was spurred by COVID? Some of these new studies and data were spurred by COVID and that led to some of this new evidence we have to support one way or another.

SPEAKER_02:

It's actually really interesting that you bring that up because it's almost a flip side of that. There was actually a trial network that uh we'll talk about maybe a little bit later today called uh the RemapCap trial group. And it was actually designed to study the ideas of treating just general community-acquired bacterial pneumonia. Um, but it was designed in a way that it would be able to be adapted very readily to a pandemic if it does occur. And again, thinking back to you know H1N1 and the different influenza pandemics we've had, it was designed to work in that setting. And then lo and behold, here we have the COVID pandemic that came out. And this trial was perfectly set up to kind of run in that direction. And I think not only that trial, but some of the other kind of branch-off trials that we've seen in the last five or six years have kind of evolved as a result of practice changes within the COVID pandemic. So I think a lot of that has helped to spur new developments and ways that clinicians are thinking about how to manage these patients different than we did maybe say 15 years ago.

SPEAKER_00:

Yeah, okay, interesting. And interesting how circumstances, you know, sort of trigger various research and that can lead to beneficial evidence that we can then use to sort of guide our practice. So, all right, well, so with that sort of stage said and some of that background, that was really helpful. And I again thinking about the the role of corticosteroids in CAP, now we'll get into some of our debate. So we have sort of the pro and the con in terms of where the role of steroids fits in for CAP. And each of you is taking a side. So we're gonna start with the pro side first in terms of why we think that corticosteroids should be used in CAP and in what situations. And for that, I'm gonna turn to you, Tristan, again. So if you want to sort of put forth your case on why steroids should be considered for CAP and in what situations.

SPEAKER_04:

Yeah, absolutely. So um kind of just to start out, making sure that quantify, like, so the the all of the information I'm gonna talk today is in our bacterial community acquired pneumonia. Um, with our viral pneumonias, there's actually, you know, we have building evidence that um corticosteroids can be harmful in some of those scenarios. So all of the data that I'm gonna be talking about today mostly factors on our bacterial community acquired pneumonias.

SPEAKER_03:

Okay, I'm just clarification.

SPEAKER_04:

Yeah, yeah, just a little bit more behind some of like our pharmacology behind like our corticosteroids. Um, it's gonna be binding those glucocorticoid receptors, it's gonna decrease some of that cytokine release and production. We're gonna have fewer neutrophils extravasate into our lung tissue, and then we can actually push some of those like immune infections from a pro-inflammatory, anti-inflammatory mechanism. So, what you get is more stabilization of that aviolar capillary barrier that I talked about earlier. So, you're not gonna see as much lung damage essentially, hopefully leading to lower rates of mechanical ventilation, but you also won't see some of that systemic spillover. So, you hopefully also won't be pushed into more of that like septic shock picture where you're gonna need baso pressure support. Kind of going back to, or another, I guess, thing that I want to explore, talk a little bit about. Um, so a lot of our studies are actually going to look at severe community acquired pneumonia specifically. So, some of our guidelines do give some general overviews. What's what's almost most important in all of these scenarios is a lot of those major criteria for meeting that definition is going to be reaching septic shock or needing baso pressors or needing mechanical ventilation to support our respiratory drive. Um, they'll come with some minor criteria that kind of just fit all those boxes, like blood pressure under this, respiratory rate over this, PF ratio under this. Kind of that's kind of how a lot of these trials are going to define that. I'm stepping back a little bit to that same meta-analysis that Sam was talking to in 2017. Um, we did see one thing that I do want to point out is that time to clinical stability is another thing that they found in some of those. So, like I said, that's going to be pointing to mostly like they have either decreased amounts of mechanical ventilation, shorter time on our mechanical ventilation, less vasopressor needs, or shorter time on vasopressors. So, just one more important thing to throw in there that really starting to point to that, like we're trying to get ahead of that inflammatory response. We're trying to avoid needing our mechanical ventilation and our vasopressors. So, next I'll be kind of talking about what I think our most important trial is that we've had come out in the last couple of years. Um, so that would be the hydrocortisone severe community-acquired pneumonia trial. So that was a randomized double-blind control trial completed from 2015 to 2020. It looked at our adult patients in the ICU looking at a severe community-acquired pneumonia diagnosis, essentially. So they kind of have their own definition that is kind of separate from the guidelines, but also kind of follows that same mainframe. Um, so they looked at if they have mechanical ventilation, if they're requiring like a high flow nasal cannula at higher oxygen rates to maintain that PF, and then a similar cutoff for like needing like a respiratory breathing mask to maintain their um uh oxygenation. Uh, but what's important about this trial is they all is a their biggest part of their exclusion criteria, is they did not look at patient or they excluded any patients who are being treated by vase suppressors on initiation. Um, so they are tried to separate out our benefit in septic shock and our actual benefit in our community acquired pneumonia, because we have do have a lot of great data pointing to turning to our hydrocortisone, like our surviving sepsis guidelines are going to point to at certain time frames and certain base suppressor needs that we should add those on. So, what this trial was really trying to show was that we haven't a direct benefit in our community acquired pneumonia. So this trial found or included it was a relatively large trial, had around 795 patients. They treated them with hydrocortisone. Um, uh, it's about 200 milligrams over 24 hours, IV infusion. And what they found was that with early treatment without hydrocortisone, we had improved mortality, we had lower rates of intubation, we had less need for vasopressors for those who obviously no one came in on vasopressor support. For a lot of those patients ended up not needing vasopressor support. And then also importantly, their savvy the safety outcomes were very similar between the groups outside of just our hydrocortisone group needing a little bit higher insulin use because we do expect that increase in our blood glucose when we're on our hydrocortisone. Um, so I think what's really important is I think this is really one of the most best design trials that we have in our community acquired pneumonia patients specifically, especially looking at that more severe patient population. And following that study, we actually do have some new guideline recommendations from some of these large bodies. So we have our SECM steroid guidelines, um, so our Society of Critical Care Medicine, who now do recommend administering corticosteroids in our severe community acquired pneumonia. And then just this year in 2025, we had our American Thoracic Society Community Acquired Pneumonia Guidelines come out, and they also recommend our systemic corticosteroids in our adult patients with severe community acquired pneumonia. So I think based on that trial is some of the best data that we have. And I think our new guideline recommendations kind of reflect, you know, that patient population that we should be targeting.

SPEAKER_00:

Okay, so fantastic summary of the data and sort of where we are now on the pro-critical steroid side of things. And I think you called it a few things that are important to highlight. So outcomes. So like Sam had mentioned mortality. You talked about some of these other outcomes, like delaying time to intubation and that sort of thing, right? Like other non-mortality-based outcomes. So that's a good clarification. And then also your point about severe cap versus non-severe cap and focusing on those patients with severe cap is where you were, right, Tristan? Okay, so severe cap versus non-severe cap. And there are some of those clear distinctions based on clear cut criteria on who meets that severe qualification. And that could be, like you say, mechanical ventilation or vasopressors, or some of these other criteria that build up if you have a few of them.

SPEAKER_04:

Like essentially someone building to those things as well. Like if we're starting to see drops in blood pressure, um, if someone is requiring more and more respiratory support to stay stable, like building towards those is another great indicator that we're looking for to like where this is where our corticosteroids should come in.

SPEAKER_00:

Okay, gotcha. And then you also mentioned the guidelines, and I think that's another, probably a whole other discussion in itself about the the American Thoracic Society guidelines, not endorsed by IDSA previous time around, whereas the 2019 guidelines were from both societies. So another sort of interesting wrinkle in this discussion. Um, but yes, the fact that they they do recommend it for patients with severe CAP, but also without influenza. And you did also mention that, like not thinking about viral, we're focused on bacterial. So again, another good sort of nuance for for listeners to just be focused in on. So super interesting. And thank you for that overview on the pro side. And now let's move to the con side of things, Sam. You know, Tristan has made some interesting points, and you know, the idea of like getting ahead of something before patients become more severely ill, I think is an interesting perspective. So, what role do you think steroids should play in the in patients with CAP or not play? And and why would you maybe not be on the side of using steroids in some of these patients?

SPEAKER_02:

Yeah, we get to ask all the all the fun and challenging questions here today. But I I I think it's an excellent clinical question that I think we all need to be asking ourselves as we practice in this area. And Tristan did a very good job of kind of describing the the very pro side of steroids and why we are even talking about this here today, because obviously anything that we can do as clinicians to improve outcomes in our patients, especially something in the ICU that increases mortal or decreases mortality, um, we're gonna jump on that, right? Because we want to help our patients the best we can. With that said though, I I do think as clinicians, we need to be somewhat cautious with over-extrapolating results from a single study. We want to make sure that we're looking at the the holistic breadth of all of the literature before we jump in and make overreaching conclusions because we've been burned in the past. We've had other medications, including you know, activated protein C that originally looked very promising, and then we jumped on it and we came back later and hey, this isn't the panacea that we thought it was going to be at baseline. So uh what I would generally like to think about with the the the world of corticosteroid literature in the last four years is and Tristan did a great job of summarizing the the largest trial, which is the Cape Cod study that was published in the New England Journal of Medicine. But concurrently or similar time frame to that study's publication, we had two other major randomized controlled trials get published. One of them was the Escape study, and this was published by Madurian colleagues that looked primary primarily at a VA patient population. And the study, when they conducted it, looking at a similar severe community-quired pneumonia standpoint, treating these patients with methyl prednisolum, they were terminated early for slow enrollment and did not find any major benefit in any clinical outcome, including mortality, despite having a fairly large patient population as a whole. And then the the more contemporary study that actually came out this year was the publication of what we talked about before, the remap cap study, which is a very unique designed trial, as it is an adaptive platform network study. And what this means is they essentially created an For patients to kind of get randomized in different ratios to different groups as the patient population and data became more clear. And so as the one treatment arm starts beating out the other treatment arms, they'll start to funnel more patients into the arm that's winning, so to speak, so that we can maximize the benefit that we get from patients in the study. Now, there's a a lot of statistical uh jargon that comes in when we talk about studies like this. And to be honest, a lot of it is difficult to interpret for the the frontline clinician. And so um when you take that trial in as a whole, the big conclusion that comes out of it is there was actually no major benefit in the patients who received hydrocortisone, a very similar trial protocol to the Cape Cod study. And the trial actually ended up getting stopped early, and that was on account of there being a trend towards worse outcomes in the steroid arm. Now, again, there's a lot of limitations to that study that we could go and do almost an entire separate podcast to kind of walk through in detail. But in general, now when we take these three big randomized control trials and we put them together and we look head to head, we have one study that shows a significant benefit. And we have two studies that are a little more lukewarm and not necessarily suggesting that same magnitude that we saw before. And so again, this should give us pause as clinicians as to exactly what we should take away from these studies. And I think to really hammer home the point from a clinical practice perspective, I have three major kind of key features of things that I think are are still gray areas that we don't really know the correct answer to and how we apply these um this literature around steroids to our clinical practice. And the first and foremost is similar to what both you and Tristan had hit on before is that severe cap definition. And so we have seen studies previous to these more modern publications that looked at a patient population that was not severely ill. These are the early stages of community-acquired pneumonia where they're not necessarily in my ICU yet. Um and when we studied those patients that received corticosteroids, there was really no benefit that was demonstrated. If anything, we just increased the risk of hyperglycemia. And that kind of brings up the question of when is the optimal timing to administer these medications? Do we give it right away, as you said, get ahead of it and prevent this patient from getting worse? Or do we need to wait until they hit a certain threshold of sickness? And sometimes that's difficult to predict. Some patients might get better without any intervention, some patients might deteriorate rapidly without intervention. And where do you find that exact kind of uh tipping point? And then to further elaborate on that, even the definitions within the different studies, within the IDSA criteria, within other societies' criteria for what constitutes severe CAP differ greatly. And while I overall I agree in practice, very similar to how Tristan laid out his thought process on severe community-acquired pneumonia, there's maybe some nuances in each individual trial patient population of to as to why we saw different results. And so what exact criteria should we use in clinical practice is still kind of a gray area. And then lastly, I think it's it's also important to think about what steroid are we using and how are we dosing it, right? We've had a ton of heterogeneity across these studies. You know, the Cape Cod trial protocol was the 200 milligrams of hydrocortisone a day. Well, is that better than 300 milligrams? Is that better than methyl prednisolone? Is that better than dexamethasone, which has excellent data in both ARDS and in our COVID patient population? Which of these medications is really the optimal approach to managing our patients? And right now, I don't think we have a definitive answer to that pending the publication of some upcoming randomized control trials that hopefully will help to shed some light on that.

SPEAKER_00:

Very interesting. Yeah, lots of sort of unanswered questions, I think, that you brought up. And I mean, I like the fact that you mentioned sometimes we get some positive data and go down one path and then maybe see that, you know, we once we have more real-world experience or even more, you know, study experience, we have a change in that thought process. So definitely something to not go full force into necessarily, depending on the level of data that we have to support a move one way or another. And then as you mentioned, some of those differences in the corticosteroid. Why do you think that would be? What would be the reasons why a uh one corticostero versus another might matter in terms of patient outcomes? Is there any thought process to that at all?

SPEAKER_02:

Or yeah, it's a really interesting question. And it's kind of a conundrum that we haven't really been able to figure out the exact answer to. In theory, when we're looking at the the relative corticosteroid effects of these different drugs, we look at the glucocorticoid effects and we look at the mineralocorticoid effects. And a medication like hydrocortisone is pretty well balanced between its gluco and mineralocorticoid effects. In theory, if you're looking at trying to tamper down inflammation related to pneumonia, the glucocorticoid effects would be the real, the heavy hitter, the high driving property that we're looking for, whereas mineralocorticoid effects generally deal with water retention, which, if anything, might worsen outcomes in a patient with severe pneumonia where we want to remove that fluid from their lungs. Um, which is interesting that we see studies with hydrocortisone showing the most promise, which has the highest mineralocorticoid effect potency relative to some of our other agents. In theory, deximethasone would be you know, where it's 100% glucocorticoid, no mineralocorticoid effects, would be the the ideal agent. And I just don't think that we have enough data to really suggest 100% that that is the case and that there's no additional effects that are you know a little bit off-target off of our traditional rationale that might make a huge difference in outcomes.

SPEAKER_00:

Super interesting. Yeah, that's yeah, very interesting, counter to what you might think. But then the whole dosing question is also a sort of side lingering, lingering question. All right, so you both sort of laid out your sides. Tristan, do you want to sort of come back to any of Sam's points and share your thoughts on his perspective and some of the concerns he shared with not jumping into full force at this point?

SPEAKER_04:

Yeah, absolutely. So without jumping into a ton of other data and things to support, like he makes a very good point about like our data kind of pointing back and forth and what like what are those proper definitions? Um, it's it's also one thing, like when you're pointing, like, you know, he spoke to some of those systematic analyses that's looking for mortality benefit across these. When you're using all these different steroid regimens and you have all these different definitions, it's obviously going to be nearly impossible to find like a group benefit of between them. So, really, you know, my point of view is like what is our best data that we have today? And I still think that is the Cape Cod trial. I think we have data and other things, like without going into too depth. We also have another trial that looked at the approaches trial. So that looked at hydrocortisone plus flujacortisone. So that flujacortisone is going to be like our entire mineral corticoid agent. Um, and they looked at septic shock, and in one of their subsets, one of the only groups they found benefit in is going to be that community acquired pneumonia group. So I think we have some, I think our strongest data is behind that hydrocortisone. Um, so I very much am still in favor of that as far as like some of the other negative effects that we might see across. Really, the only thing we're seeing across all trials is going to be that increased glucose levels. Like some of those other things that providers certainly worry about would be like that immune suppression if you're using these, if you're using these agents, or G, I believe, is gonna be another big one. In those effects, you know, we would we would more expect to see that in our long-term glucocorticoid patients. And I think that's why these outcome, like our safety outcomes, aren't really differing very highly between groups, especially when you have a reasonably set time that they're getting them. Like some of our like our Cape Cod trial, uh, very interesting. They had kind of an interesting way of like timing out how patients should get it. They had patients who got it for four days and eight days. The overall average day's amount of treatment is about five days, and they had a very interesting if the patient was discharged from ICU, they would stop our quota-core steroids completely. So we might kind of hit this on our kind of closing statements, but looking at like at that data, you know, not being on these long term is also a big part of like we don't we don't want to be sending people out into the community to get like oral steroids. Right. Um, you know, we'll be sending them out most likely on their continued antibiotic regimens, um, but these shouldn't be like long term. This is in the hospital in that severe community acquired pneumonia definition. And yeah, like bedside, what I'm looking for, you're gonna be looking for that confirmed suspicion for our community-acquired pneumonia. And we have these patients that are decomposing relatively quickly, they're having worsening respiratory support, signs of hypoperfusion, need for vasopressor administration. And I think that was all very well laid out and structured in our CAPECOD trial. So that's kind of, like I said, my biggest basis for my support for hydrochlorosome.

SPEAKER_00:

Yeah, interesting. So you brought up two points I want to circle back on. One is the concept of discontinuing at discharge. That sounds like a clear-cut answer because we are focused on inpatients with severe CAP and mostly ICU patients. And so we're we're not this is not extending to outpatients at all. And I think that's an important clarification to make. So an outpatient who sees their outpatient provider and gets an antibiotic, they're corticosteroids are not in that realm at all that of decision making. Is that right?

SPEAKER_04:

Yep, that is correct. Yeah, this is for like our decompensating patients on the inpatient side of things that are you know escalating towards like our ICU cares. And but important to point out, like it doesn't necessarily have to be ICU. These patients can like there are other floors, our IMC floors, our general med search floors, where these patients can be decompensating. And you know, putting these corticore steroids out in front of that using that criteria that I've kind of laid out might prevent their need to come to the ICU. So it's it's very interesting, I think, like in the hospital. You know, obviously, if you're discharging, if you're you know, stepping down from ICU care, that would be a great time for them to come off. Um, but on like our our med search side of things, if if you're you know, if you're either on your way out of the hospital or you're seeing significant improvement around those like five-day marks, that's another great time to get it off. And then yeah, we don't want to be sending patients out on like a seven-day taper of prednisone courses.

SPEAKER_00:

And actually, that's a great point too. No taper needed, it's just discontinue. That's it.

SPEAKER_04:

Correct. Yeah, we don't see a lot of differences in benefits based on like that direct cutoff. Like the Cape Cud, the Cape Cod trial showed that that you know, as soon as they left the ICU, they cut that off. But we in like in most scenarios, like if you were to talk to a provider, like our like our hydrocortisone dosing, you know, is gonna be like very similar to like just like a 40 milligrams of pretnisone daily. And obviously, it wouldn't, if we'd been doing that for just a couple of days, we wouldn't need this long outdrawn taper.

SPEAKER_00:

Okay, okay, that's an excellent point to clarify too. And I I feel like, yeah, patient education is gonna be important here too, just in terms of you know, transitioning to outpatient and what you do need to continue, what you don't need to continue if any meds were changed in the hospital. Obviously, the whole medication reconciliation side of things too is super important with this population. Um, one other thing I wanted to come back to in terms of the side effects that you mentioned and the concern about hypoglycemia, and you know, how some of these other concerns around immunosuppression are maybe not as much of an issue just because of these shorter durations, for example. But thinking about that hypoglycemia concern, does this lead you to individualize any further based on a patient's personal history? If they have a history of diabetes, for example, are you any more or less inclined to think about a corticosteroid in that patient based on their medical history, or is that not something that necessarily comes into play?

SPEAKER_04:

Yeah, that's that's a great question. I I don't think I would I wouldn't be scared to start like a hydrocortisone like due to a patient who has like a history of diabetes or a history of hyperglycemia. Um, you know, we we are expecting that rise in blood glucose. So, you know, like me as like an ICU pharmacist or other inpatient pharmacists, like we're gonna be on top of like that's that's a really big role that pharmacists will have is like being on top of like do we have like our sinuscale insulin in place for these patients who are on steroids? Um, because we we do want to be monitoring it, but it's it's not something that you know we're we're seeing these, like we're seeing across all these trials that we have those increased glycemia levels, but they're not really correlating to any sort of negative effects, essentially. So we don't we don't have any data saying that that hyperglycemia in those scenarios is causing harm. But once again, we also probably don't have any great data saying that it's not. But overall, I think it's more about being on top of the management of that glucose than it is about avoiding steroids because someone is at higher risk of having hyperglycemia.

SPEAKER_00:

Okay, okay, that's a great clarification. Sam, anything you want to counter to what Tristan just said before we were wrap up?

SPEAKER_02:

Or no, honestly, I think uh Keith uh made some very good points in terms of our way of operationalizing and using this in clinical practice.

SPEAKER_00:

So excellent. Well, we I think we've it sounds like we've sort of come to a consensus that you could go both ways, right? There's as you say, there's a gray area here, like with anything in clinical practice, it's often not black and white. And so there may be differing opinions, but hearing you both share your perspectives, I think has been really helpful to sort of help listeners also come to their own bottom line. And if there's anything else you want to share to make your case one last time before we wrap up with our game changer, please do so now. But otherwise, yeah, I'll just open the floor for any last-minute thoughts or rebuttals.

SPEAKER_02:

Yeah, and Rachel, I think overall, you know, I I took on a very, you know, controversial con side role here with the steroid management. But I think in general, like thinking my my overall clinical thoughts on use of steroids in these patients, is I'm generally a believer. And again, it kind of goes back to my thought process at the beginning of, you know, any time there is an intervention that may change outcomes like that in a critically ill patient, we like to jump on them. And while I I still, you know, urge caution with over-extrapolation and jumping on small you know studies and overreaching their conclusions, um, the the data that we have when we sum everything up, including, as I mentioned before, all of those studies that were published recently, there was a mate analysis that was conducted that took all of those trials together and the Cape Cod study. So even those studies that look negative or even potentially harmful for steroids, when you put them all together, the end result is that steroids still change um mortality and they still improve outcomes for patients. And so as a result of that, I I do agree with the society guidelines and how things have have evolved and updated and what our practice is trending towards. But I do think, you know, as we'll we'll touch on here with a game changer more likely, I think the patient selection, the timing of administration, and the appropriate patient management are really the key factors to make sure that we get those outcomes that we're seeing in the studies. If we just throw it on everyone, we probably won't see anywhere near that same result. But if we do things with a very concentrated, intentional way, I think we can save lives by using steroids.

SPEAKER_00:

So because our our podcast is clinical game changers, would would you say that that is the game changer here, Sam?

SPEAKER_02:

I would indeed. I I think uh steroids are the uh I think the way we're moving are are the future of cap management in those severe patient populations with the intention to the the right patient selection, the right timing, and the correct patient monitoring and management.

SPEAKER_00:

That's excellent. And I think that really does circle back to what you were saying too, Tristan, you know, making sure that we're staying on top of you know, these care, the care for these patients and managing them appropriately and not just throwing it at everyone. So it sounds like you two are in alignment there.

SPEAKER_04:

Yes, absolutely. We are in very good alignment. And, you know, that's and speaking to the pharmacist roles in the hospital, like that's you know, this is going to be a big one because we are going to be on those front lines and looking at some of those criteria, you know, because we might be the ones at bedside being like, you know, I think this patient really would benefit from a dose or, you know, from starting our hydrocortisone regimen. So yeah, like being on the front lines, being able to initiate those therapies as soon as possible, um, you know, kind of straying away from like our sepsis survival guidance, like maybe we should wait a couple hours first. Like, I think the data we have now really supports like pharmacists in hospital to kind of get on top of that and get those hydrocortisone or your other steroids in place.

SPEAKER_00:

Excellent. Well, I love the message of ending with the role of the pharmacist and how we can help optimize care because that's obviously what we are all very excited and passionate about. So super appreciate that that final perspective. Thank you both so much. Really appreciate your time. And I'm glad we could come to an alignment at the end. It sounds like, you know, there is debate, but of course, you know, it's nice to reach agreement where we can.

SPEAKER_04:

Absolutely.

SPEAKER_00:

Well, thank you both so much for your time and for the great discussion and the debate. You know, this is a very interesting format for us, I think, in Game Changers Closing Conversation. So just really excited to sort of explore this topic in this way. And the collegiality you both have is wonderful. So really good to have this sort of consensus after this controversial topic. And listeners, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.