Vitamin C for the treatment of sepsis: The scientific rationale

Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis

INTRODUCTION

We aimed to study the use of ascorbic acid, thiamine, and steroids (ATS) in patients with septic shock (SS).

METHODS

Data on 62 patients with SS were collected from Acute Physiologic and Chronic Health Evaluation (APACHE) Outcome database and medical records. The ATS group received full doses of intravenous (IV) ATS (ascorbic acid [1.5 g every 6 hours for 4 days], hydrocortisone [50 mg every 6 hours for 7 days], and thiamine [200 mg every 12 hours for 4 days]). Data included age, gender, APACHE III, acute physiologic score (APS), mechanical ventilation (MV), lactic acid (LA), serum creatinine (Cr), duration of vasopressors (VP, days, median: interquartile ranges [IQR]: [Q1, Q3]), MV-free days (median: IQR [Q1-Q3]), percentage of patients requiring renal replacement therapy (RRT) for acute kidney injury (AKI), and mortality. Propensity analysis was used to match patients on age, gender, MV, APACHE III, APS, LA, and Cr.

RESULTS

The ATS group had longer duration of VP (4.5: 4.0-6.0 vs 2.0: 1.0-2.0, P = .001), similar RRT for AKI (26% vs 29%, P = .8), similar MV-free days (10.2: 5.0-15.0 vs 10.2: 1.6-18.0, P > .9), lower intensive care unit mortality (9.6% vs 42%, P = .004), and a trend toward lower hospital mortality (29% vs 45%, P = .2) compared to the NO ATS group.

CONCLUSIONS

The use of IV ascorbic acid, thiamine, and hydrocortisone might be beneficial in patients with SS.

High-Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review

Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states.

Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders

BACKGROUND

At least a third of the world's population consumes alcohol regularly. Patients with alcohol use disorders (AUDs) are frequently hospitalized for both alcohol-related and unrelated medical conditions. It is well recognized that patients with an AUD are thiamine deficient with thiamine replacement therapy being considered the standard of care. However, the incidence of vitamin C deficiency in this patient population has been poorly defined.

METHODS

In this retrospective, observational study, we recorded the admission vitamin C level in patients with an AUD admitted to our medical intensive care unit (MICU) over a 1-year period. In addition, we recorded relevant clinical and laboratory data including the day 2 and day 3 vitamin C level following empiric treatment with vitamin C. Septic patients were excluded from this study.

RESULTS

Sixty-nine patients met the inclusion criteria for this study. The patients' mean age was 53 ± 14 years; 52 patients (75%) were males. Severe alcohol withdrawal syndrome was the commonest admitting diagnosis (46%). Eighteen patients (26%) had cirrhosis as the admitting diagnosis with 18 (13%) patients admitted due to alcohol/drug intoxication. Forty-six patients (67%) had evidence of acute alcoholic hepatitis. The mean admission vitamin C level was 17.0 ± 18.1 μmol/l (normal 40-60 μmol/l). Sixty-one (88%) patients had a level less than 40 μmol/l (subnormal) while 52 patients (75%) had hypovitaminosis C (level < 23 μmol/l). None of the variables recorded predicted the vitamin C level. Various vitamin C replacement dosing strategies were used. A 1.5-g loading dose, followed by 500-mg PO q 6, was effective in restoring blood levels to normal by day 2.

CONCLUSION

Our results suggest that hypovitaminosis C is exceedingly common in patients with an AUD admitted to an intensive care unit and that all such patients should receive supplementation with vitamin C in addition to thiamine. Additional studies are required to confirm the findings of our observational study and to determine the optimal vitamin C dosing strategy.

Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation

The combination of thiamine, ascorbic acid, and hydrocortisone has recently emerged as a potential adjunctive therapy to antibiotics, infectious source control, and supportive care for patients with sepsis and septic shock. In the present manuscript, we provide a comprehensive review of the pathophysiologic basis and supporting research for each element of the thiamine, ascorbic acid, and hydrocortisone drug combination in sepsis. In addition, we describe potential areas of synergy between these therapies and discuss the strengths/weaknesses of the two studies to date which have evaluated the drug combination in patients with severe infection. Finally, we describe the current state of current clinical practice as it relates to the thiamine, ascorbic acid, and hydrocortisone combination and present an overview of the randomized, placebo-controlled, multi-center Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial and other planned/ongoing randomized clinical trials.

The role of glucocorticoids as adjunctive treatment for sepsis in the modern era

Glucocorticoids have been used as adjunctive therapy in patients with sepsis and septic shock for more than four decades. The rationale for the use of glucocorticoids is that this class of drugs downregulates the proinflammatory response and limits the anti-inflammatory response while preserving innate immunity. Between 1976 and 2017, 22 randomised placebo-controlled trials have been published evaluating the benefit of glucocorticoids in patients with community-acquired pneumonia, sepsis, and septic shock. These studies produced conflicting results. In 2018, two large randomised controlled trials (RCTs) were published evaluating the role of hydrocortisone in patients with septic shock. The Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trial reported a reduction in 90-day mortality whereas the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial reported no mortality benefit. This Viewpoint critically appraises these two RCTs and evaluates the use of glucocorticoids in the treatment of sepsis and septic shock in the modern era.