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January 1, 2003

Corticosteroids for Patients With Septic Shock

JAMA. 2003;289(1):41-44. doi:10.1001/jama.289.1.41-a

To the Editor: Dr Annane and colleagues1 justify a 1-sided statistical test based on their lack of concern about a possible deleterious effect with low-dose corticosteroids plus fludrocortisone. To support their argument they cite 2 studies in which low-dose corticosteroids without fludrocortisone were used to treat patients with severe sepsis. The first is a small observational study in which only 12 patients with severe sepsis received low-dose corticosteroids.2 In the other study by McKee et al,3 8 of 18 patients were randomized to receive low doses of hydrocortisone. All 18 patients had clear adrenal insufficiency with serum cortisol levels below 12.5 µg/dL without significant increase in serum cortisol levels after corticotropin stimulation test, a population clearly different from that studied by Annane et al. In fact, most patients enrolled by McKee et al were receiving etomidate infusions,4 a drug known to decrease adrenal cortical response to corticotropin through selective inhibition of 11 β-hydroxylase. I am not convinced that the small number of patients in the above-mentioned studies are sufficient to assume that low doses of corticosteroids are not harmful in patients who may already have a high serum cortisol level in response to severe sepsis.

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