Steroid Therapy

Steroid Therapy: The French multi-center RCT (hypotension despite fluid resuscitation and vasopressors) Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871.

Conclusion Significant shock reversal and reduction of mortality rate in patients with relative adrenal insufficiency (defined as post-adrenocorticotropic hormone (ACTH) cortisol increase 9 µg/dL or less)

P = .045 P = .007 Briegel J, Forst H, Haller M, et al. Stress doses of hydrocortisone reverse hyperdynamic septic shock: A prospective, randomized, double-blind, single-center study. Crit Care Med. 1999;27:723-732. Bollaert PE, Charpentier C, Levy B, et al. Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med. 1998;26:645-650.

Corticosteroid Therapy of Septic Shock CORTICUS European multi-center RCT

Hydrocortisone Therapy for Patients with Septic Shock Charles L. Sprung, M.D., Djillali Annane, M.D., Ph.D., Didier Keh, M.D., Rui Moreno, M.D., Ph.D., Mervyn Singer, M.D., F.R.C.P., Klaus Freivogel, Ph.D., Yoram G. Weiss, M.D., Julie Benbenishty, R.N., Armin Kalenka, M.D., Helmuth Forst, M.D., Ph.D., Pierre-Francois Laterre, M.D., Konrad Reinhart, M.D., Brian H. Cuthbertson, M.D., Didier Payen, M.D., Ph.D., Josef Briegel, M.D., Ph.D., for the CORTICUS Study Group N Engl J Med Volume 358(2):111-124 January 10, 2008

Study Overview The benefit of adjuvant use of corticosteroids in patients with septic shock remains controversial In this international, multicenter, double-blind, placebo-controlled trial, adjunctive therapy with hydrocortisone in nearly 500 patients with septic shock was not found to be clinically helpful This lack of benefit was also found in a subgroup of patients who did not have a response to a corticotropin test

Eligibility Criteria Clinical evidence of infection Inclusion Exclusion Clinical evidence of infection Evidence of a systemic response to infection The onset of shock within the previous 72 hours (as defined by a systolic blood pressure of <90 mm Hg despite adequate fluid replacement or a need for vasopressors for at least 1 hour) Hypoperfusion or organ dysfunction attributable to sepsis. Underlying disease with a poor prognosis, a life expectancy of less than 24 hours Immunosuppression Treatment with long-term corticosteroids within the past 6 months or Short-term corticosteroids within the past 4 weeks.

Definitions Organ-system failure was defined for each of the six major organ systems as a Sequential Organ Failure Assessment (SOFA) score of 3 or 4 points (on a scale ranging from 0 to 4 for each organ system, for an aggregate score of 0 to 24, with higher scores indicating more severe organ dysfunction). Reversal of shock was defined as the maintenance of a systolic blood pressure of at least 90 mm Hg without vasopressor support for at least 24 hours. Superinfection was defined as a new infection occurring 48 hours or more after the initiation of a study drug. New sepsis was defined as a new septic episode with or without microbiologic confirmation. New septic shock was defined as a new episode of septic shock after reversal of the initial episode. The absence of a response to a corticotropin test was defined as an increase in the cortisol level of no more than 9 μg per deciliter (248 nmol per liter).

End Points The primary end point: Secondary end points were: The rate of death at 28 days in patients who did not have a response to corticotropin. Secondary end points were: The rates of death at 28 days in patients who had a response to corticotropin and in all patients The rates of death in the ICU and in the hospital, The rates of death at 1 year after randomization, A reversal of organ system failure (including shock) duration of the stay in the ICU and the hospital.

Enrollment and Outcomes Figure 1. Enrollment and Outcomes.

Demographic Characteristics of the Patients, According to Subgroup Table 1. Demographic Characteristics of the Patients, According to Subgroup.

Clinical Characteristics of the Patients at Baseline, According to Subgroup Table 2. Clinical Characteristics of the Patients at Baseline, According to Subgroup.

Kaplan-Meier Curves for Survival at 28 Days Figure 2. Kaplan-Meier Curves for Survival at 28 Days. For the comparison between patients with septic shock who received hydrocortisone and those who received placebo, there was no significant difference among those who did not have a response to a corticotropin test (Panel A), those who had a response to corticotropin (Panel B), and all patients who underwent evaluation (Panel C).

Outcomes According to Subgroup Table 3. Outcomes According to Subgroup.

Figure 3. Kaplan-Meier Curves for the Time to Reversal of Shock Figure 3. Kaplan-Meier Curves for the Time to Reversal of Shock. For the comparison between patients with septic shock who received hydrocortisone and those who received placebo, P=0.06 for patients who did not have a response to a corticotropin test (Panel A) and P<0.001 both for patients who had a response to corticotropin (Panel B) and for all patients (Panel C).

Adverse Events (Per-Protocol Population) Table 4. Adverse Events (Per-Protocol Population).

Conclusion Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed

Annane vs Sprung Annane Sprung Setting Multicenter: 19 ICUs in France Multicenter 52 ICUs in Europe Patients 300 499 SAPS II 58.5 49.5±17.8 Inclusion Systolic blood pressure was less than 90 mm Hg for more than 1 hour despite fluid and vasopressor Systolic blood pressure of <90 mm Hg despite adequate fluid replacement or a need for vasopressors for at least 1 hour Enrollment window 8 hours 72 hours Medication Hydrocortisone + fludrocortisone Hydrocortisone Medication stop Abrupt after 7 days Taper over 6 days 28 Day Placebo Death 61% 32%

Streoid Therapy Consider intravenous hydrocortisone for adult septic shock when hypotension remains poorly responsive to adequate fluid resuscitation and vasopressors. (2C) ACTH stimulation test is not recommended to identify the subset of adults with septic shock who should receive hydrocortisone. (2B) Hydrocortisone is preferred to dexamethasone. (2B) Fludrocortisone (50µg orally once a day) may be included if an alternative to hydrocortisone is being used which lacks significant mineralocorticoid activity. Fludrocortisone is optional if hydrocortisone is used. (2C) Steroid therapy may be weaned once vasopressors are no longer required. (2D) Hydrocortisone dose should be ≤300 mg/day. (1A) Do not use corticosteroids to treat sepsis in the absence of shock unless the patient’s endocrine or corticosteroid history warrants it. (1D)

ACTH Stimulation Test

Kaplan-Meier Curves for Survival at 28 Days Figure 2. Kaplan-Meier Curves for Survival at 28 Days. For the comparison between patients with septic shock who received hydrocortisone and those who received placebo, there was no significant difference among those who did not have a response to a corticotropin test (Panel A), those who had a response to corticotropin (Panel B), and all patients who underwent evaluation (Panel C).

Streoid Therapy Consider intravenous hydrocortisone for adult septic shock when hypotension remains poorly responsive to adequate fluid resuscitation and vasopressors. (2C) ACTH stimulation test is not recommended to identify the subset of adults with septic shock who should receive hydrocortisone. (2B) Hydrocortisone is preferred to dexamethasone. (2B) Fludrocortisone (50µg orally once a day) may be included if an alternative to hydrocortisone is being used which lacks significant mineralocorticoid activity. Fludrocortisone is optional if hydrocortisone is used. (2C) Steroid therapy may be weaned once vasopressors are no longer required. (2D) Hydrocortisone dose should be ≤300 mg/day. (1A) Do not use corticosteroids to treat sepsis in the absence of shock unless the patient’s endocrine or corticosteroid history warrants it. (1D)