Do We Need to Administer Fludrocortisone in Addition to Hydrocortisone in Adult Patients With Septic Shock? An Updated Systematic Review With Bayesian Network Meta-Analysis of Randomized Controlled Trials and an Observational Study With Target Trial Emulation

Abstract

Objectives: This systematic review and Bayesian network meta-analysis evaluated the efficacy and safety of hydrocortisone combined with fludrocortisone or hydrocortisone alone, compared with placebo in adult patients with septic shock.

Data sources: By extending a prior Cochrane review, databases, including PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov , along with other relevant websites, were searched until August 31, 2023.

Study selection: Randomized controlled trials (RCTs) and observational studies using target trial emulation were included.

Data extraction: The primary outcome was short-term mortality with an emphasis on 28- or 30-day mortality as the main measure and in-hospital or ICU mortality as the nearest surrogate of this measure. Three of the most common adverse events, namely, gastroduodenal bleeding, superinfection, and hyperglycemia, were also considered.

Data synthesis: A total of 19 studies involving 95,841 patients were included. Hydrocortisone plus fludrocortisone showed the lowest short-term mortality versus placebo (odds ratio [OR]: 0.79; 95% credible interval [CrI], 0.64-0.99; number needed to treat [NNT]: 21, range: 12-500; low certainty of evidence) in terms of informative priors. The surface under the cumulative ranking curve values for hydrocortisone plus fludrocortisone, hydrocortisone alone, and placebo were 0.9469, 0.4542, and 0.0989, respectively. Consistent results were observed in RCTs alone and those using a daily 200-mg dose of hydrocortisone. Although gastroduodenal bleeding or superinfection showed no clear increase, hyperglycemia risk increased. The ORs were 0.53 for placebo versus hydrocortisone plus fludrocortisone and 0.64 for placebo versus hydrocortisone alone, with very low certainty of evidence.

Conclusions: In adults with septic shock, hydrocortisone plus fludrocortisone improved short-term survival with minimal adverse events compared with hydrocortisone alone or placebo. However, these findings are not definitive due to the limited certainty of evidence and wide NNT range. Additional large-scale, placebo-controlled RCTs are needed to provide conclusive evidence.

Figure 1.

Search in accordance with the flow diagram of Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. RCT = randomized controlled trial, SRMA = systematic review and meta-analysis.

Figure 2.

Forest plots presenting the odds ratios for short-term mortality among treatment groups receiving either combined hydrocortisone and fludrocortisone, hydrocortisone alone, or placebo: includes all studies (A); has been narrowed down to randomized controlled trials (B); and specifically examines randomized controlled trials administering an initial daily hydrocortisone dosage of 200 mg (C). CrI = credible interval, OR = odds ratio.

Figure 3.

Rankogram illustrating the probability rankings for improving short-term mortality across treatments: combined hydrocortisone and fludrocortisone, hydrocortisone alone, or placebo: encompasses all studies (A); is limited to randomized controlled trials (B); and highlights randomized controlled trials starting with a daily hydrocortisone dose of 200 mg (C).