Key Messages from a lecture by Dr Philip Judge at Zoomies 2026

This lecture provides a comprehensive examination of the current evidence for glucocorticoid use in small animal emergency and critical care settings. This lecture critically evaluates the role of corticosteroids across a range of common emergency and critical illness presentations. The content spans septic shock, acute respiratory distress syndrome, pneumonia, anaphylaxis, pancreatitis, meningitis, and neurological trauma, offering practical guidance on when steroids may be beneficial, when they are ineffective, and when they cause genuine harm.

1. Physiological Dosing Is the New Paradigm

The days of high-dose corticosteroid therapy for shock are behind us. Historical protocols using dexamethasone sodium phosphate at 4 mg/kg or methylprednisolone at 30 mg/kg caused significant gastrointestinal mucosal damage and offered no survival benefit. Modern practice centres on physiological replacement dosing, typically 0.1 to 0.25 mg/kg/day of prednisolone or 0.4 to 1 mg/kg/day of hydrocortisone. These doses aim to restore vascular responsiveness, improve catecholamine sensitivity, and support gluconeogenesis, rather than suppress inflammation. For patients weighing over 25 kg, clinicians should cap immunosuppressive doses at 60-80 mg per day, as higher amounts do not appear to provide additional benefit while increasing adverse effect risks.

2. Septic Shock: The Strongest Case for Corticosteroid Use

Critical illness-related corticosteroid insufficiency (CIRCI) affects up to 60% of human septic shock patients and has been documented in dogs and cats with severe inflammation. The CIRCI diagnostic pathway involves a patient with vasopressor-refractory hypotension, meaning fluid resuscitation has failed and noradrenaline (or dopamine) cannot maintain mean arterial pressure above 65 mmHg or systolic pressure above 90-100 mmHg. In these cases, hydrocortisone at 1 mg/kg IV, followed by a continuous infusion of 0.08-0.16 mg/kg/hour, can restore blood pressure within several minutes. 

In sepsis without shock, meta-analyses in humans also shows low-dose hydrocortisone may reduce mortality, shorten ICU stays, and accelerate resolution of vasopressor-dependent shock. High-dose protocols from the 1970s are obsolete and should never be used.

3. Respiratory Conditions: A Mixed Picture

Acute respiratory distress syndrome (ARDS) is characterised by severe hypoxemia, with a PaO2/FiO2 ratio below 200, acute onset, and exclusion of left atrial hypertension. 

Human meta-analyses suggest corticosteroids may reduce mortality and increase ventilator-free days, but only if started early – initiation after 14 days of illness worsens outcomes. In veterinary medicine, evidence is limited to case reports, offering little further insight. 

For community-acquired pneumonia and aspiration pneumonia, the evidence is even weaker; meta-analyses show no mortality benefit across all severity grades, though the sickest patients might gain some advantage. 

If used, methylprednisolone sodium succinate is preferred for lung penetration at 1-2 mg/kg/day. 

For feline asthma, inhaled fluticasone (44-110 mcg twice daily) minimises systemic side effects, while acute exacerbations may require dexamethasone at 0.1-0.5 mg/kg for its superior pulmonary penetration.

4. When Corticosteroids Are Unhelpful or Harmful

Traumatic brain injury: Corticosteroids worsen outcomes, primarily through hyperglycaemia which exacerbates neurological damage. Routine use is contraindicated. The only exception is the rare case of documented pituitary dysfunction following trauma, confirmed by brain imaging.

Spinal cord injury: Methylprednisolone sodium succinate protocols show no improvement in ambulation. Complication rates are alarmingly high, with one study reporting 76% gastrointestinal ulceration and 35% developing vomiting or diarrhoea. These drugs offer no benefit and carry substantial risks.

Anaphylaxis: Despite decades of use, there is no compelling evidence that corticosteroids prevent reactions or improve outcomes. Epinephrine (adrenaline) remains the first-line treatment. Dexamethasone might be considered only for protracted dermatological symptoms, but routine use is not recommended.

5. Promising Applications in Selected Conditions

Acute pancreatitis: A 2019 study of 68 dogs with severe acute pancreatitis found that prednisolone at 1 mg/kg/day significantly reduced C-reactive protein concentrations, shortened hospitalisation, and improved survival in the most severely affected patients. While not a first-line therapy, corticosteroids deserve consideration in cases deteriorating despite supportive care.

Infectious meningitis: Dexamethasone at 0.15 mg/kg every six hours, initiated before or with the first antibiotic dose, shows benefit in human pneumococcal meningitis and has support from veterinary case reports. Its superior CSF penetration and longer duration of action make it the drug of choice. More studies are needed, but early use is recommended until clinical improvement occurs.

6. Adverse Effects Require Careful Risk-Benefit Analysis

Corticosteroids carry significant and potentially life-threatening adverse effects that must be weighed before administration. Gastrointestinal mucosal injury can progress to ulceration, haemorrhage, and even colonic perforation, particularly in patients with concurrent illnesses or reduced gastric perfusion. Prolonged therapy (exceeding two weeks) causes hypothalamic-pituitary-adrenal axis suppression and adrenal atrophy, leaving patients unable to mount stress responses. 

Hyperglycaemia, hypernatraemia, and hypokalaemia are common electrolyte disturbances. 

Critical illness myopathy is a recognised complication in humans, especially when neuromuscular blocking agents are used. 

Polyuria, polydipsia, and polyphagia, though inconvenient, are generally manageable. 

Finally, in recumbent or paralysed patients, corticosteroids increase susceptibility to respiratory infections due to impaired secretion clearance.

7. Clinical Decision-Making in an Evidence-Limited Landscape

Veterinary medicine lacks large prospective controlled trials for most corticosteroid indications, forcing clinicians to extrapolate from human literature that is itself often contradictory. This leaves practitioners navigating a challenging balance between historical tradition and emerging evidence. The key practical recommendations include:

• Septic shock: Use hydrocortisone only after documenting poor response to fluids and vasopressors. Additionally, a requirement for prolonged vasopressor support may support use of hydrocortisone in a similar manner for treatment of CIRCI
• ARDS: Consider methylprednisolone early in rapidly deteriorating patients.
• Pneumonia: Reserve for severely unwell patients, acknowledging limited evidence.
• Pancreatitis: Consider prednisolone for refractory severe cases.
• Meningitis: Initiate dexamethasone early, concurrently with antimicrobial therapy.
• Anaphylaxis: Avoid routine use; rely on adrenaline.
• Neurological trauma: Avoid completely, except rare pituitary dysfunction.

In all cases, use the lowest effective physiological dose, monitor for adverse effects, and taper therapy over several days after 3-4 days of initial treatment. With the notable exception of sepsis and meningitis, corticosteroids are frequently not the answer our patients need, and their use demands careful justification.