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To the Editor: Dr Annane and colleagues¹ reported a reduction in the risk of death among vasopressor-dependent septic shock patients with relative adrenal insufficiency when treated with low-dose hydrocortisone and fludrocortisone. Adrenal insufficiency was assessed by measuring cortisol level increase following a short 250-µg corticotropin stimulating test. However, some recent studies have shown the low-dose corticotropin stimulating test (1 µg) to have an increased accuracy in detecting relative adrenal insufficiency over the conventional test (250 µg).^2-4 We wonder if the conventional corticotropin dose might have caused normal responses in patients with secondary adrenal insufficiency by overriding adrenal resistance to corticotropin. Consequently this might have led to mixing patients who could have benefited from corticosteroid therapy in the responder group. In light of the results of this study, this could have a considerable impact on the outcome of such patients reducing mortality difference between responders and nonresponders.

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