Transcriptional markers in response to hydrocortisone in sepsis in ADRENAL: a step toward precision medicine

Excerpt

Practice varies widely for corticosteroid usage in sepsis [1], perhaps because study results have themselves varied widely, leading to a minor recommendation within the SSC guidelines for patients in refractory shock. Still, a recent Cochrane review of 61 trials with over 12,000 participants suggests a modest but significant benefit in terms of 28-day mortality along with reduced ICU and hospital length of stay [2]. So why does practice continue to vary? Individual study results vary; the climax of this scientific dilemma occurred 2018 when two independent large RCT were published in the same issue of NEJM with contradictory results (APROCCHSS and ADRENAL; the studies also had differences in severity of illness and steroid dosing). The largest study of these, ADRENAL (N = 3658), showed no mortality benefit with corticosteroids, but shorter time in shock and on mechanical ventilation [3]. In addition, there are negative side effects; the same Cochrane review showed increased rates of hypernatremia and hyperglycemia with corticosteroid usage. …