Early administration of hydrocortisone, vitamin C, and thiamine in adult patients with septic shock: a randomized controlled clinical trial

Qing-Quan Lyu, Rui-Qiang Zheng, Qi-Hong Chen, Jiang-Quan Yu, Jun Shao, Xiao-Hua Gu, Qing-Quan Lyu, Rui-Qiang Zheng, Qi-Hong Chen, Jiang-Quan Yu, Jun Shao, Xiao-Hua Gu

Abstract

Background: The combination therapy of hydrocortisone, vitamin C, and thiamine has been proposed as a potential treatment in patients with sepsis and septic shock. However, subsequent trials have reported conflicting results in relation to survival outcomes. Hence, we performed this randomized controlled trial (RCT) to evaluate the efficacy and safety of early combination therapy among adult patients with septic shock.

Methods: This single-center, double-blind RCT enrolled adult patients with diagnosis of septic shock within 12 h from Northern Jiangsu People's Hospital between February 2019 and June 2021. Recruited patients were randomized 1:1 to receive intervention (hydrocortisone 200 mg daily, vitamin C 2 g every 6 h, and thiamine 200 mg every 12 h) or placebo (0.9% saline) for 5 days or until ICU discharge. The primary endpoint was 90-day mortality. The secondary endpoints included mortality at day 28, ICU discharge, and hospital discharge; shock reversal; 72-h Delta SOFA score; ICU-free days, vasopressor-free days, and ventilator support -free days up to day 28; ICU length of stay (LOS) and hospital LOS.

Results: Among 426 patients randomized, a total of 408 patients with septic shock were included in the per-protocol (PP) analysis, of which 203 were assigned to the intervention group and 205 to the placebo group. In the PP population, the primary outcome of 90-day mortality was 39.9% (81/203) and 39.0% (80/205) in the intervention and the placebo groups, respectively, and was not significantly different (P = 0.86). There was no significant difference between two groups in 28-day mortality (36.5% vs. 36.1%, P = 0.94) or the ICU mortality (31.5% vs. 28.8%, P = 0.55) and hospital mortality (34.5% vs. 33.2%, P = 0.78). No other secondary outcomes showed significant differences between two groups, including shock reversal, vasopressor-free days, and ICU LOS. Intention-to-treat analysis included all the 426 patients and confirmed these results (all P > 0.05).

Conclusion: Among adult patients with septic shock, early use of hydrocortisone, vitamin C, and thiamine combination therapy compared with placebo did not confer survival benefits. Trial registration ClinicalTrials.gov: NCT03872011 , registration date: March 12, 2019.

Keywords: Hydrocortisone; Mortality; Septic shock; Thiamine; Vitamin C.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Study flowchart
Fig. 2
Fig. 2
Kaplan–Meier estimates of survival rate distribution among patients in the intervention or placebo group. Panel A shows analysis of the intention-to-treat population. A log-rank (Mantel–Cox) test P = 0.62 for intergroup differences in survival rate distribution. Hazard ratio for mortality is 1.08; 95% CI 0.80–1.46. Panel B shows analysis of the per-protocol population. Log-rank (Mantel–Cox) test P = 0.67 for intergroup differences in survival rate distribution. Hazard ratio for mortality is 1.07; 95% CI 0.79–1.46

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