氟氢可的松与单独使用氢化可的松对比在脓毒性休克患者中的疗效。

Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock.

机构信息

The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Department of Medicine, Boston, Massachusetts.

Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario.

出版信息

JAMA Intern Med. 2023 May 1;183(5):451-459. doi: 10.1001/jamainternmed.2023.0258.

DOI:10.1001/jamainternmed.2023.0258

PMID:36972033

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10043800/

Abstract

IMPORTANCE

Patients with septic shock may benefit from the initiation of corticosteroids. However, the comparative effectiveness of the 2 most studied corticosteroid regimens (hydrocortisone with fludrocortisone vs hydrocortisone alone) is unclear.

OBJECTIVE

To compare the effectiveness of adding fludrocortisone to hydrocortisone vs hydrocortisone alone among patients with septic shock using target trial emulation.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study from 2016 to 2020 used the enhanced claims-based Premier Healthcare Database, which included approximately 25% of US hospitalizations. Participants were adult patients hospitalized with septic shock and receiving norepinephrine who began hydrocortisone treatment. Data analysis was performed from May 2022 to December 2022.

EXPOSURE

Addition of fludrocortisone on the same calendar day that hydrocortisone treatment was initiated vs use of hydrocortisone alone.

MAIN OUTCOME AND MEASURES

Composite of hospital death or discharge to hospice. Adjusted risk differences were calculated using doubly robust targeted maximum likelihood estimation.

RESULTS

Analyses included 88 275 patients, 2280 who began treatment with hydrocortisone-fludrocortisone (median [IQR] age, 64 [54-73] years; 1041 female; 1239 male) and 85 995 (median [IQR] age, 67 [57-76] years; 42 136 female; 43 859 male) who began treatment with hydrocortisone alone. The primary composite outcome of death in hospital or discharge to hospice occurred among 1076 (47.2%) patients treated with hydrocortisone-fludrocortisone vs 43 669 (50.8%) treated with hydrocortisone alone (adjusted absolute risk difference, -3.7%; 95% CI, -4.2% to -3.1%; P < .001).

CONCLUSIONS AND RELEVANCE

In this comparative effectiveness cohort study among adult patients with septic shock who began hydrocortisone treatment, the addition of fludrocortisone was superior to hydrocortisone alone.

摘要

重要性

脓毒性休克患者可能受益于皮质类固醇的启动。然而，两种研究最多的皮质类固醇方案（氢化可的松加氟氢可的松与单独使用氢化可的松）的比较效果尚不清楚。

目的

使用目标试验仿真比较在脓毒性休克患者中添加氟氢可的松与单独使用氢化可的松对患者的有效性。

设计、设置和参与者：这是一项从 2016 年到 2020 年的回顾性队列研究，使用了增强的基于索赔的 Premier Healthcare 数据库，该数据库包含了大约 25%的美国住院患者。参与者为接受去甲肾上腺素治疗并开始接受氢化可的松治疗的住院脓毒性休克成年患者。数据分析于 2022 年 5 月至 2022 年 12 月进行。

暴露

在开始氢化可的松治疗的同一天添加氟氢可的松与单独使用氢化可的松。

主要结果和测量

医院死亡或临终关怀出院的复合结果。使用双重稳健靶向最大似然估计计算调整后的风险差异。

结果

分析包括 88275 名患者，其中 2280 名患者开始接受氢化可的松-氟氢可的松治疗（中位[IQR]年龄 64[54-73]岁；1041 名女性；1239 名男性），85995 名（中位[IQR]年龄 67[57-76]岁；42136 名女性；43859 名男性）患者开始单独接受氢化可的松治疗。在接受氢化可的松-氟氢可的松治疗的患者中，有 1076 名（47.2%）患者发生医院死亡或临终关怀出院的主要复合结局，而在接受氢化可的松单独治疗的患者中，有 43669 名（50.8%）患者发生该结局（调整后的绝对风险差异，-3.7%；95%CI，-4.2%至-3.1%；P<0.001）。