Tuesday, January 15, 2008

The CORTICUS study hits the pages of NEJM

Retired Doc and Case Blog have already linked to the paper. The study failed to show benefit from stress doses of corticosteroids in patients with septic shock.

This isn’t news. Although it was just published in Thursday’s NEJM the study has been out for a while and I have referenced it several times. But with its publication in a high profile medical journal it is now susceptible to sound bite reporting. Any spin that “steroids are out” is simplistic.

Like any research findings this study must be interpreted in light of what was known before. Earlier data suggesting that corticosteroids were useful were collected from more severely ill patients than those in CORTICUS. In my November post about discussion of this issue at the Mayo update in hospital medicine I noted that while blanket recommendations for steroids in patients with sepsis are no longer justified, critical illness related corticosteroid insufficiency (CIRCI) is common in patients with septic shock and a judicious strategy of patient selection focusing on more ill patients such as those reported in earlier studies may be warranted. Moreover, classic adrenal insufficiency as may be cause by adrenal infarction, adrenal hemorrhage or prior corticosteroid therapy warrants evaluation and treatment and represents a separate issue.

In my top ten issues post about the sepsis bundle I predicted a more restrictive recommendation for corticosteroids based on the CORTICUS findings. In a subsequent post on the release of the new Surviving Sepsis Guidelines I noted that the guidelines, apparently taking into account CORTICUS, had downgraded the steroid recommendation and recommended more limited patient selection.

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