Start Giving Vitamin C to Septic Patients Now!

It sounds almost too good to be true. Dr. Paul Marik, the Chief of Pul­monary and Crit­i­cal Care Med­i­cine at East­ern Vir­ginia Med­ical School, in Nor­folk, Vir­ginia, has found that a cock­tail of intra­venous vit­a­min C and cor­ti­cos­teroids, along with a lit­tle bit of thi­amine, may be a cure for sep­sis, which is a major cause of death. (Sep­sis killed Pat­ty Duke and Muham­mad Ali.) Many physi­cians are skep­ti­cal of Marik’s claim, for two rea­sons. First, they have heard a lot of non­sense about vit­a­min C over the years. Sec­ond, they have been trained to wait for the results of a dou­ble-blind ran­dom­ized con­trolled tri­al before they make any change in how they prac­tice med­i­cine. As a result, they may be slow to adopt Marik’s pro­to­col. But if they hes­i­tate, they will miss the chance to save lives. Physi­cians have noth­ing to lose by try­ing the Marik’s pro­to­col. Patients have every­thing to lose if their physi­cian hes­i­tates.

Marik’s break­through came in Jan­u­ary of 2016, as he strug­gled to save the life of a 48-year-old woman suf­fer­ing from over­whelm­ing sep­sis. He had recent­ly read that vit­a­min C might be a use­ful treat­ment for sep­sis. He recalled that steroids, which are com­mon­ly used for treat­ing sep­sis, might work well in con­cert with vit­a­min C. So he ordered that the patient be giv­en a com­bi­na­tion of steroids and vit­a­min C intra­venous­ly. With­in hours, she start­ed to recov­er. Two days lat­er, she was well enough to leave the inten­sive care unit. Then, Marik and his col­leagues used the same treat­ment on two more patients who seemed des­tined to die of sep­sis. Those patients also recov­ered. At that point, Marik and his team adopt­ed the com­bi­na­tion ther­a­py as stan­dard prac­tice. They even­tu­al­ly added a small dose of thi­amine to the pro­to­col, because sep­sis patients are also often defi­cient in thi­amine. Since then, they have not seen a sin­gle patient die of sep­sis. (How­ev­er, some did die of the under­ly­ing dis­ease that led to sep­sis.)

Marik’s claims have been sup­port­ed by an ade­quate­ly pow­ered clin­i­cal study. How­ev­er, that study was ret­ro­spec­tive. It com­pared 47 con­sec­u­tive sep­tic patients treat­ed with his pro­to­col to 47 sep­tic patients who had been treat­ed before his insti­tu­tion began using the pro­to­col. Only 4 of the 47 patients treat­ed with the vit­a­min C pro­to­col died, as com­pared with 19 of the 47 patients in the con­trol group (P<.001). Most impor­tant­ly, none of the patients in the treat­ment group devel­oped pro­gres­sive organ fail­ure. That find­ing sug­gests that the treat­ment is effec­tive against the sep­sis, in par­tic­u­lar.

Marik’s claim makes bio­log­i­cal sense. In 2012, Wil­son and Wu explained the mech­a­nisms by which vit­a­min C could improve microvas­cu­lar func­tion in sep­sis patients. They explained that the vit­a­min C would have to be giv­en intra­venous­ly to pro­vide ade­quate ascor­bate con­cen­tra­tions in plas­ma and tis­sue. In 2015, Carr et al point­ed out that sep­tic patients present with hypovi­t­a­minosis C and explained that the enzymes that are involved in the syn­the­sis of nor­ep­i­neph­rine and vaso­pressin require vit­a­min C as a cofac­tor for opti­mal activ­i­ty.

Some method­olog­i­cal purists may quib­ble about the sup­posed “flaws” of the design of Marik’s study. They may insist on a prospec­tive, ran­dom­ized, place­bo-con­trolled study before they adopt the vit­a­min C pro­to­col. Yet such a study would vio­late a basic prin­ci­ple of med­ical research ethics. Researchers are not sup­posed to assign patients with a seri­ous ill­ness to dif­fer­ent treat­ment arms unless there is real uncer­tain­ty about which of the treat­ments would be bet­ter. This prin­ci­ple is called clin­i­cal equipoise. Yet there is no real uncer­tain­ty. The prob­a­bil­i­ty that the results of the ret­ro­spec­tive study were due to ran­dom chance are less than one in a thou­sand. Nor was there any rea­son to sus­pect that the dif­fer­ences in out­come were due to any con­found­ing vari­ables. Nor are there any seri­ous safe­ty con­cerns about adding vit­a­min C and some thi­amine to the com­mon­ly used cor­ti­cos­teroid treat­ment for sep­sis.

Reg­u­la­to­ry agen­cies typ­i­cal­ly require drug com­pa­nies to do dou­ble-blind, ran­dom­ized con­trolled tri­als to sup­port a new drug appli­ca­tion. Yet there are some excep­tions. For exam­ple, the Food and Drug Admin­is­tra­tion approved lep­irudin (Reflu­dan®) for anti­co­ag­u­la­tion in patients with heparin-induced throm­bo­cy­tope­nia on the basis of a clin­i­cal tri­al that used his­tor­i­cal con­trols, rather than assign­ing patients to a place­bo treat­ment that would have threat­ened life and limb.

So we now know that a vit­a­min C, which is a cheap, eas­i­ly avail­able prod­uct with a long his­to­ry of safe use, is prob­a­bly the key to the suc­cess­ful treat­ment of a major cause of death. The med­ical pro­fes­sion will be judged by how fast or how slow­ly it acts on this infor­ma­tion.

Pho­to by Unhin­dered by Tal­ent