Metabolic Resuscitation Using Ascorbic Acid, Thiamine, and Glucocorticoids in Sepsis.

The global burden of sepsis is substantial with an estimated 15 to 19 million cases per year;
the vast majority of these cases occur in low income countries. With more timely diagnosis
and improvement in supportive care the 28-day mortality from sepsis in high income countries
has declined to about 25%, however, the mortality from septic shock remains as high as 45%.
Moreover, the mortality from sepsis and septic shock in low income countries is reported to
be as high as 60%. In addition to short term mortality, septic patients suffer from a
numerous short- and long-term complications and are at an increased risk of death for up to
five years following the acute event. Over the last 3 decades over 100 phase II and phase III
clinical trial have been performed testing various novel pharmacologic agents and therapeutic
intervention in an attempt to improve the outcome of patients with sepsis and septic shock;
all of these studies have failed to show an improvement in patient outcomes. New therapeutic
approaches to sepsis are desperately required; considering the global burden of sepsis these
interventions should be effective, cheap, safe and readily available.

A large body of experimental data has demonstrated that both corticosteroids and intravenous
vitamin C reduce activation of nuclear factor ƘB (NFƘB) attenuating the release of
pro-inflammatory mediators, reduce the endothelial injury characteristic of sepsis thereby
reducing endothelial permeability and improving macrocirculatory flow, augment the release of
endogenous catecholamines and enhance vasopressor responsiveness. In animal models these
effects have resulted in reduced organ injury and increased survival. Corticosteroids have
been evaluated in several clinical trials, with meta-analysis of these trials demonstrating
somewhat conflicting outcomes. Low-dose stress corticosteroids have proven to be safe with no
increased risk of clinically important complications. While corticosteroids decrease
vasopressor dependency the effect on survival is less clear.

Several studies have investigated the use of intravenous vitamin C in critically ill
patients. Nathens et al randomized 595 surgical ICU patients (91% trauma patients) to receive
intravenous vitamin C and vitamin E for up to 28 days.The vitamin combination was associated
with a significant reduction in the incidence of multiple system organ failure (p=0.04) with
a trend to reduced mortality and length of ICU stay. No adverse effects were noted with the
vitamin combination. Fowler et al performed a pilot study in 24 patients with severe sepsis
and septic shock. In this study patients were randomized to placebo (n=8), low dose
intravenous vitamin C (50 mg/kg) (n=8) or high dose vitamin C (200mg/kg). Vitamin C
attenuated the inflammatory response with both doses of the vitamin being devoid of any side
effects. Although the Sequential Sepsis Related Organ Failure Score (SOFA) fell significantly
in both treatment arms the study was underpowered to determine any outcome benefit. Zabet and
colleagues performed a randomized controlled trial (RCT) in which they evaluated the role of
intravenous vitamin C in a dose of 100 mg/kg/day (about 7g/day) in 28 surgical ICU patients
with septic shock. In this study the mean dose of norepinephrine and duration of
norepinephrine administration were significantly lower in the ascorbic acid than the placebo
group. The 28-day mortality was significantly lower in the ascorbic acid than the placebo
group (14% vs. 64%, p = 0.009). No side effects related to the vitamin C infusion were
reported. Tanaka et al randomized 37 patients with severe burn to very high dose vitamin C
(about 110g/day) or placebo. Patients who received vitamin C required less fluid
resuscitation with a trend towards reduced length of stay and mortality. No adverse effects
were noted with the very high dosages of vitamin C. Several studies have administered vitamin
C in doses exceeding 100g/day as adjuvant therapy in patients with cancer with no discernable
side effects. Vitamin C appears to be toxic to normal human cells (not cancer cells) at a
concentration on greater than 25 millimole (mM). A dose of 6g/day will achieve a steady state
serum concentration of about 240 micromole (uM) which is about 100 times less than the dose
required to cause cellular toxicity. The package insert for vitamin C lists no
contraindications or adverse effects of the drug and states that as much as "6 grams has been
administered without evidence of toxicity". The only reported restriction to the use of high
dose intravenous vitamin C is in patients with known glucose-6-phosphate deficiency (G6PD) in
whom hemolysis has been reported. It is important to recognize that patents with sepsis
predictably have very low serum vitamin C levels, which can only be corrected with
intravenous vitamin C in a dose of more than 3gm per day. The low or undetectable levels of
vitamin C likely result from the metabolic consumption of the molecule as well as increased
renal losses. Furthermore, unlike all other mammals, primates and guinea pigs are unable
synthesize vitamin C is due to mutations in the L-gulono-_-lactone oxidase (GLO) gene which
codes for the enzyme responsible for catalyzing the last step of vitamin C biosynthesis. In
almost all species, except humans and guinea pigs, vitamin C production increases during
stress and is secreted by the adrenal gland; in these species vitamin C is best considered a
stress "hormone". Vitamin C is an essential cofactor for the production of corticosteroids
and catecholamines by the adrenal gland. Vitamin C has been shown to reverse adrenal
suppression caused by induction doses of etomidate during anesthesia.

Ascorbate donates a single electron in all its redox reactions, generating the ascorbate
radical. This radical is not very reactive with anything but itself. Dismutation of two
ascorbate radicals forms a molecule each of ascorbate and dehydroascorbate. Hydrolysis of the
lactone ring of dehydroascorbate irreversibly converts it to 2,3-diketo-1-gulonic acid which
is then converted to oxalate. Oxalate is normally excreted by the kidney and serum levels
will increase with renal impairment. In patients with renal impairment receiving mega-dose
vitamin C, supersaturation of serum with oxalate may result in tissue deposition as well as
crystallization in the kidney. Glyoxylate, a byproduct of intermediary metabolism, is either
reduced to oxalate or oxidized to carbon dioxide (CO2) by the enzyme glyoxylate
aminotransferase; thiamine pyrophosphate is a co-enzyme required for this reaction. Thiamine
deficiency increases the conversion of glyoxylate to oxalate resulting in hyper- oxalosis.
Donnino and colleagues have demonstrated that thiamine deficiency is common (32%) in patients
with sepsis and that treatment with thiamine in these patients reduces mortality. In a
post-hoc analysis of this study these authors demonstrated that thiamine decreased the risk
of acute kidney injury and the required for renal replacement therapy in all treated
patients.

It has previously been suggested that "...the best hope for therapeutic advances [in sepsis]
will depend on broad-base targeting, in which multiple components are targeted at the same
time." Such combination "chemo-therapy" targeting multiple biological pathways is the
standard approach in the treatment of malignant disease. While the benefits of vitamin C,
hydrocortisone, and thiamine alone are likely limited, the investigators believe that these
medications act synergistically to reduce the risk of organ failure and death in patients
with sepsis. This hypothesis is supported previous research and more recently a set of
elegant experiments performed by Barabutis et al. Using a validated pulmonary endothelial
monolayer model, these authors demonstrated that hydrocortisone together with vitamin C
protected the vascular endothelium from damage by endotoxin while neither agent alone had
this effect. Previous research has demonstrated that vitamin C reverses oxidation of the
glucocorticoid receptor (GR) a likely manifestation of sepsis. Oxidation of the GR limits
binding of the GR to both ligand and DNA responsive units decreasing the activity of
glucocorticoids. Furthermore, glucocorticoids increase the expression of the sodium vitamin C
transporter-2 (SVCT-2) which is an essential transport protein necessary for vitamin C to be
transported intracellularly.

The investigators therefore propose that a "metabolic resuscitation protocol" including
vitamin C, corticosteroids and thiamine will limit the development of organ failure and
reduce mortality in patients with severe sepsis and septic shock. This postulate is supported
by the preliminary findings by Marik et al. In a retrospective before-after clinical study,
these authors compared the outcome and clinical course of consecutive septic patients treated
with intravenous vitamin C, hydrocortisone and thiamine during a 7-month period (treatment
group) compared to a control group treated in during the preceding 7 months. The primary
outcome was hospital survival. A propensity score was generated to adjust the primary
outcome. There were 47 patients in both treatment and control groups with no significant
differences in baseline characteristics between the two groups. The hospital mortality was
8.5% (4 of 47) in the treatment group compared to 40.4% (19 of 47) in the control group (p <
0.001). The propensity adjusted odds of mortality in the patients treated with the vitamin C
protocol was 0.13 (95% CI 0.04-0.48, p=0.002). The SOFA score decreased in all patients in
the treatment group with none developing progressive organ failure. Vasopressors were weaned
off all patients in the treatment group, a mean of 18.3 ± 9.8 hours after starting treatment
with vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 hours in the
control group (p<0.001). The results of this study provide sufficient information for the
design of an adequately powered, pragmatic randomized controlled trial.

Inclusion Criteria:

i. Diagnosis of sepsis or septic shock within 12 hours of admission to the ICU ii. Informed
consent as dictated by IRB and local practice. iii. Compliance with the 3 hour sepsis
bundle

- 30ml/kg of intravenous crystalloid fluid (e.g.: sodium chloride 0.9%) for lactic acid
>4 and/or systolic blood pressure <90mmHg / mean arterial pressure <65mmHg

- Lactic acid level drawn

- Broad spectrum antibiotics given after obtaining blood cultures

Exclusion Criteria:

i. Age < 18 years ii. Pregnant iii. DNR/DNI with limitations of care on admission iv.
Patients with terminal end stage disease (i.e. stage IV cancer, end stage heart failure)
that are unlikely to survive to hospital discharge v. Patients with a primary admitting
diagnosis of an acute cerebral vascular event, acute coronary syndrome, active
gastrointestinal bleeding, burn or trauma [64-66] vi. Requirement for immediate surgery
[64-66] vii. Patients with HIV and a CD4 < 50 mm2 [64-66] viii. Patients with known
glucose-6 phosphate dehydrogenase (G-6PD) deficiency.[39] ix. Patients with sepsis/septic
shock transferred from another hospital x. Patients with features of sepsis/septic shock >
24 hours after admission