2026 Southeastern Residency Conference

Comparison of Dexamethasone versus Methylprednisolone in Acute Respiratory Distress Syndrome (ARDS)
Authors: Kayla Phillips, PharmD, Lindsey Mclendon PharmD Candidate, Lauren Floris, PharmD, BCPS, BCCCP
Background:
Acute respiratory distress syndrome (ARDS) represents about ten percent of all intensive care unit (ICU) admissions with nearly a fourth of these requiring intubation.1 Early phase ARDS is characterized by alveolar inflammation leading to hypoxemia.3 Steroids can inhibit the progression of this inflammation by decreasing cytokine release and promoting clearance of alveolar edema.2 The Society of Critical Care Medicine (SCCM) consensus update in 2024 suggests using corticosteroids in all patients with ARDS, regardless of the severity but no drug or dosing regimen was advised over another.4 The purpose of this study is to determine if there is a difference in duration of mechanical ventilation when either dexamethasone or methylprednisolone is used in the management of ARDS.
Methods:
We conducted a single center, retrospective, chart review to evaluate the effects of dexamethasone compared to methylprednisolone in adults ICU patients diagnosed with ARDS. This study included adult patients admitted from January 1, 2021, to August 31, 2025, who were intubated with a diagnosis of ARDS and received either intravenous (IV) dexamethasone or IV methylprednisolone within 72 hours of intubation. Patients who received both dexamethasone and methylprednisolone, diagnosed with COVID-19, history of adrenal insufficiency, prescribed steroids at baseline, or those who only received one dose of IV steroids were excluded from this study. The primary outcome was days alive and ventilator free at 28 days compared between the two steroid groups. Secondary outcomes included duration of mechanical ventilation, duration of steroid use, ICU and hospital length of stay, rate of ICU readmission within 90 days, ARDS severity defined by PaO2/FiO2 ratio, and mortality rate. Safety outcomes recorded are hypernatremia, fluid overload, uncontrolled hyperglycemia requiring insulin, gastrointestinal bleeding, and new infection acquired during admission post-steroid use.
Results:
A total of 45 patients were included (22 dexamethasone, 23 methylprednisolone). Baseline characteristics were similar between groups. There was no significant difference in the primary outcome of days alive and ventilator-free at 28 days between dexamethasone and methylprednisolone, 16 days vs 15.2 days respectively (p= 0.82). Secondary outcomes including ICU readmission within 90 days, did not differ between groups (2/22 vs 0/23, p=0.14). Safety outcomes were comparable with no significant differences in rates of hyponatremia (6/22 vs 7/23, p=0.82) or hyperglycemia requiring insulin (13/22 vs 18/23, p=0.17).
Conclusion:
In this single center retrospective study of patients with ARDS, dexamethasone and methylprednisolone were associated with similar ventilator free days and comparable secondary and safety outcomes. This study was not powered to detect small differences between treatment groups, and larger prospective studies are needed to further evaluate optimal corticosteroid selection.