In this episode, I’ll discuss adding fludrocortisone to hydrocortisone to treat patients with septic shock.
There is a discordance in steroid recommendations for patients with septic shock between the Surviving Sepsis Guidelines, which recommend giving hydrocortisone and the 2020 Japanese Clinical Practice Guidelines for Sepsis and Septic Shock which recommend adding fludrocortisone to hydrocortisone in this patient population.
Although hydrocortisone does have mineralocorticoid activity, the potency of fludrocortisone is well over 100 times that of hydrocortisone on mineralocorticoid receptors. Many studies have suggest a benefit to combining fludrocortisone with hydrocortisone and this makes therapeutic sense because the production of endogenous mineralocorticoid activity is impaired in patients with sepsis. However, the evidence is apparently not conclusive enough given the disagreement between expert guidelines for septic shock patients, and a group of authors sought to update previous systematic review and meta-analysis to include more recent trials in an attempt to bring clarity to the subject.
This updated review and meta-analysis was published in Critical Care Medicine and examined over 95,000 patients in 19 different studies who received hydrocortisone alone or hydrocortisone plus fludrocortisone. Hydrocortisone plus fludrocortisone showed the lowest short-term mortality compared to placebo with a number-needed-to-treat of just 21. However it should be noted that the 95% credibility interval ranged from a number-needed-to-treat of 12 all the way to 500. Gastroduodenal ulcer risk was the same between groups however the combination group had more hyperglycemia.
Despite the finding in favor of adding fludrocortisone to hydrocortisone, the authors believe that the large range in number-needed-to-treat indicates the result is not conclusive enough to warrant a clear recommendation. However, the authors state “Given the affordability and accessibility of fludrocortisone, its coadministration with IV hydrocortisone is an appropriate option for patients receiving enteral nutrition.” and the journal editors state, “On the basis of the aforementioned evidence, the combined administration of hydrocortisone and fludrocortisone may be considered for adult patients with septic shock.” These statements indicate many clinicians will probably opt for giving fludrocortisone, but guideline and quality metrics focused on giving fludrocortisone to all septic shock patients will not be forthcoming until more conclusive evidence is available.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply