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BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b2417 (Published 16 June 2009)
Cite this as: BMJ 2009;338:b2417

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Uncertainty continues over steroids for sepsis

Corticosteroids have a long history in the treatment of septic shock. The evidence has gone first one way, then the other, with dedicated critical care doctors not far behind, says an editorial (pp 2388-90). In 2002, the United States briefly ran out of hydrocortisone after an unusually rapid and enthusiastic response to a positive French trial of low dose therapy. More recently, longer courses of low doses have fallen out of favour. Current guidelines sit on the fence with “suggestions” rather than recommendations, citing weaknesses in the evidence for their uncertainty.

The latest addition to this messy situation is a meta-analysis of all potentially relevant trials, including 12 trials that looked specifically at the benefits of at least five days of low dose corticosteroids. This low dose strategy was associated with lower mortality at 28 days than a high dose approach (236/629 (37.5%) v 264/599 (44.1%); risk ratio 0.84, 95% confidence interval 0.72 to 0.97).

The authors of this study and the authors of the editorial agree this subanalysis cannot be the final word, however. Other analyses of all trials (short and long duration of treatment; high and low doses) failed to find conclusive evidence of benefit.

Clearly, health professionals caring for patients with severe sepsis and septic shock will have to live with uncertainty for at least a little while longer, says the editorial. Doctors should embrace this uncertainty, then share it with patients and their relatives. For now, “the final decision rests squarely on those at the bedside.”

Six months of androgen suppression is not enough for men with locally advanced prostate cancer

Long term androgen suppression prolongs survival in men who have had radiotherapy for locally advanced prostate cancer. Treatment with analogues of luteinising hormone releasing hormone causes unpleasant side effects though, including poor sex drive, hot flushes, heart attacks, and fractures. Can men safely stop androgen suppression after just six …

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