Solumedrol Treatment for Severe Sepsis in Humans with a Blunted Adrenocorticotropic Hormone-Cortisol Response: A Prospective Randomized Double-Blind Placebo-Controlled Pilot Clinical Trial.

Abstract

PURPOSE\nTo test the benefits of Solumedrol treatment in sepsis patients with a blunted adrenocorticotropic hormone (ACTH)-cortisol response (delta <13\u2005µg/dL) with regard to the number of days on ventilator, days on intravenous blood pressure support, length of time in an intensive care unit (ICU), 14-day mortality, and 28-day mortality. The trial was prospective, randomized, and double-blind. As part of a larger sepsis trial, 54 patients with sepsis had an intravenous ACTH stimulation test using 250\u2005µg of ACTH, and serum cortisol was measured at times 0, 30, and 60\u2005min. Eleven patients failed to increase their cortisol concentration above 19.9\u2005µg/dL and were excluded from the clinical trial as they were considered to have adrenal insufficiency. The remaining 43 patients had a baseline cortisol of 32\u2009±\u20091\u2005µg/dL increased to 38\u2009±\u20093\u2005µg/dL at 30\u2005min and 40\u2009±\u20093 at 60\u2005min. All cortisol responses were <12.9\u2005µg/dL between time 0 and time 60, which is defined as a blunted cortisol response to intravenous ACTH administration. Twenty-one were randomized to receive 20\u2005mg of intravenous Solumedrol and 22 were randomized to receive a matching placebo every 8\u2005h for 7-days. There was no significant difference between the two randomized groups. Data analysis was carried out bya two-tailed test and P\u2009<\u2009.05 as significant.\n\n\nRESULTS\nResults: The mean age was 51\u2009±\u20092 (mean\u2009±\u2009SEM) with 61% female. Groups were well matched with regard to APACHE III score in Solumedrol versus placebo (59\u2009±\u20096 vs 59\u2009±\u20096), white blood cell count (18.8\u2009±\u20092.2 vs 18.6\u2009±\u20092.6), and incidence of bacteremia (29 vs 39%). The 28-day mortality rate was reduced in the Solumedrol treated arm (43\u2009±\u200911 vs 73\u2009±\u200910%; P\u2009<\u2009.05). There was no change in days in ICU, days on blood pressure agents, or days on ventilator. Seven days of high-dose intravenous Solumedrol treatment (20\u2005mg every 8\u2005h) in patients with a blunted cortisol response to ACTH was associated with an improved 28-day survival. This small study suggests that an inability to increase endogenous cortisol production in patients with sepsis who are then provided steroid treatment could improve survival.