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To the Editor: Dr Annane and colleagues¹ justify a 1-sided statistical test based on their lack of concern about a possible deleterious effect with low-dose corticosteroids plus fludrocortisone. To support their argument they cite 2 studies in which low-dose corticosteroids without fludrocortisone were used to treat patients with severe sepsis. The first is a small observational study in which only 12 patients with severe sepsis received low-dose corticosteroids.² In the other study by McKee et al,³ 8 of 18 patients were randomized to receive low doses of hydrocortisone. All 18 patients had clear adrenal insufficiency with serum cortisol levels below 12.5 µg/dL without significant increase in serum cortisol levels after corticotropin stimulation test, a population clearly different from that studied by Annane et al. In fact, most patients enrolled by McKee et al were receiving etomidate infusions,⁴ a drug known to decrease adrenal cortical response to corticotropin through selective inhibition . . . [Full Text of this Article]

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