As before, the mainstream media covered this story. National Public Radio, which widely publicized the protocol in 2017, again took notice. Dr. Marik told NPR that “in his experience, the treatment is only effective if given within six hours after someone has suspected sepsis.” (The typical time-to-treatment with the cocktail was around 12 hours in the VITAMINS trial.) But this is simply another way of saying that early detection and treatment of severe sepsis and shock are important. The patients for whom Dr. Marik declares the protocol is effective are precisely the ones receiving timely treatments we know to be crucial, including antibiotics and, in some patients, fluids and vasopressors. It is safe to propose that for patients who do not receive these proven therapies promptly, nothing will work later. However, in the VITAMINS trial, that is not what occurred. Instead, all patients received antibiotics prior to randomization. Nor do we know how quickly patients received either antibiotics or the vitamin C cocktail in the Marik study, as these data were not reported. However, the authors of the VITAMINS trial have already indicated that a subgroup analysis that takes time-to-treatment into account may be forthcoming.
Explore This IssueACEP Now: Vol 39 – No 02 – February 2020
Eighteen other studies assessing this cocktail are under way. With that many trials, each with its own patient inclusion criteria and unique outcome measurements, one of them is bound to find some signal of benefit by chance alone. But based on the VITAMINS study, I believe we can conclude that this miracle cure is not to be. If benefit is uncovered by any of these subsequent trials, it is likely to be small and incremental at best. Knowing that, we must again widen our perspective in our continued search for therapies that can truly turn the tide against sepsis.
- Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. Chest. 2017;151(6):1229-1238.
- Fujii T, Luethi N, Young PJ, et al. Effect of vitamin C, hydrocortisone, and thiamine vs hydrocortisone alone on time alive and free of vasopressor support among patients with septic shock: the VITAMINS randomized clinical trial [published online ahead of print Jan. 17, 2020]. JAMA. doi:10.1001/jama.2019.22176.