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Paul Marik, MD, FCCP
Author and Funding Information

Thomas Jefferson University Philadelphia, PA

Correspondence to: Paul Marik, MD, FCCP, Thomas Jefferson University, Division of Pulmonary and Critical Care Medicine, 834 Walnut St, Suite 650, Philadelphia, PA 19107; e-mail: paul.marik@jefferson.edu


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(1):324. doi:10.1378/chest.09-0772
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To the Editor:

I thank Dr. Sprung and the Corticosteroid Therapy of Septic Shock (CORTICUS) investigators for their comments on my recent article in CHEST (January 2009).1 I think we can agree that the use of corticosteroids in the critically ill is a complex and controversial topic fueled largely by the lack of high-quality scientific evidence.1 The determination of which patients are most likely to benefit from therapy with corticosteroids, as well as of the optimal dose and therapeutic strategy, awaits further investigation. This, however, does not mean that the clinician should abandon the use of these potentially life-saving drugs. In addition, as is evident from the lead article in an issue of the Wall Street Journal from 2002,2 other factors not related to scientific enquiry are at play, which further clouds the murky waters.

Clinicians need to critically appraise clinical trials (especially those published in high-profile journals), and recognize their limitations and applicability, before their “conclusions” are universally adopted. The now infamous “Intensive Insulin Therapy Trial” is a case in point.3 I believe that the CORTICUS study has a number of “limitations,” which bear on the findings of the study. Most notably, the lack of clinical equipoise led to selection bias in which patients least likely to benefit from corticosteroids were randomized to participate in the study. Using published data, I calculated that only 4% of eligible patients were enrolled into the CORTICUS trial. Furthermore, the “early” termination of therapy with corticosteroids may have led to the higher incidence of shock in the treatment group. This is supported by an apparent rebound of interleukin-6 levels in this group of patients. This suggests that a longer course of corticosteroids as well as a slower taper may be required.

Marik PE. Critical illness related corticosteroid insufficiency. Chest. 2009;135:181-193. [PubMed] [CrossRef]
 
Burton TM. Why cheap drugs that appear to halt fatal sepsis go unused. Wall Street Journal. 2002; 517
 
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367. [PubMed]
 

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References

Marik PE. Critical illness related corticosteroid insufficiency. Chest. 2009;135:181-193. [PubMed] [CrossRef]
 
Burton TM. Why cheap drugs that appear to halt fatal sepsis go unused. Wall Street Journal. 2002; 517
 
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367. [PubMed]
 
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