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Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BackgroundA recent landmark randomized controlled trial (RCT) in septic patients demonstrated an increased risk of death and persistent organ dysfunction with intravenous Vitamin C (IVVC) monotherapy, which represents a disparate result from previous systematic reviews and meta-analyses (SRMA). We p...

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Main Authors:	Lee, Zheng-Yii, Ortiz-Reyes, Luis, Lew, Charles Chin Han, Hasan, M. Shahnaz, Ke, Lu, Patel, Jayshil J., Stoppe, Christian, Heyland, Daren K.
Format:	Article
Published:	Springer Science and Business Media Deutschland GmbH 2023
Subjects:	R Medicine (General) RC Internal medicine
Online Access:	http://eprints.um.edu.my/38456/
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spelling	my.um.eprints.384562024-11-10T03:53:06Z http://eprints.um.edu.my/38456/ Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis Lee, Zheng-Yii Ortiz-Reyes, Luis Lew, Charles Chin Han Hasan, M. Shahnaz Ke, Lu Patel, Jayshil J. Stoppe, Christian Heyland, Daren K. R Medicine (General) RC Internal medicine BackgroundA recent landmark randomized controlled trial (RCT) in septic patients demonstrated an increased risk of death and persistent organ dysfunction with intravenous Vitamin C (IVVC) monotherapy, which represents a disparate result from previous systematic reviews and meta-analyses (SRMA). We performed an updated SRMA of IVVC monotherapy to summarize and explore heterogeneity across current trials and conduct trial sequential analysis (TSA) to guard against type-I or type-II statistical errors.MethodsRCTs evaluating IVVC in adult critically ill patients were included. Four databases were searched from inception to 22 June 2022 without language restrictions. The primary outcome was overall mortality. Random effect meta-analysis was performed to estimate the pooled risk ratio. TSA for mortality was performed using the DerSimonian-Laird random effect model, alpha 5%, beta 10%, and relative risk reduction (RRR) of 30%, 25%, and 20%.ResultsWe included 16 RCTs (n = 2130). IVVC monotherapy is associated with significant reduction in overall mortality risk ratio (RR) 0.73, 95% confidence interval (CI) 0.60-0.89; p = 0.002; I-2 = 42%]. This finding is supported by TSA using RRR of 30% and 25%, and sensitivity analysis using fixed-effect meta-analysis. However, the certainty of our mortality finding was rated low using GRADE due to the serious risk of bias and inconsistency. In a priori subgroup analyses, we found no differences between single vs multicenter, higher (>= 10,000 mg/day) vs lower dose and sepsis vs non-sepsis trials. Post-hoc, we found no differences in subgroup analysis of earlier (< 24 h) vs delayed treatment, longer (> 4 days) vs shorter treatment duration, and low vs other risk of bias studies. IVVC may have the greatest benefit in trials that enrolled patients above (i.e., > 37.5%; RR 0.65, 95% CI 0.54-0.79) vs below (i.e., <= 37.5%; RR 0.89, 95% CI 0.68-1.16) median control group mortality (test for subgroup differences: p = 0.06), and TSA supported this.ConclusionsIVVC monotherapy may be associated with mortality benefits in critically ill patients, particularly in patients with a high risk of dying. Given the low certainty of evidence, this potentially life-saving therapy warrants further studies to identify the optimal timing, dosage, treatment duration, and patient population that will benefit most from IVVC monotherapy.PROSPERO Registration ID: CRD42022323880. Registered 7th May 2022. Springer Science and Business Media Deutschland GmbH 2023-03 Article PeerReviewed Lee, Zheng-Yii and Ortiz-Reyes, Luis and Lew, Charles Chin Han and Hasan, M. Shahnaz and Ke, Lu and Patel, Jayshil J. and Stoppe, Christian and Heyland, Daren K. (2023) Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Annals of Intensive Care, 13 (1). ISSN 21105820, DOI https://doi.org/10.1186/s13613-023-01116-x <https://doi.org/10.1186/s13613-023-01116-x>. 10.1186/s13613-023-01116-x
institution	Universiti Malaya
building	UM Library
collection	Institutional Repository
continent	Asia
country	Malaysia
content_provider	Universiti Malaya
content_source	UM Research Repository
url_provider	http://eprints.um.edu.my/
topic	R Medicine (General) RC Internal medicine
spellingShingle	R Medicine (General) RC Internal medicine Lee, Zheng-Yii Ortiz-Reyes, Luis Lew, Charles Chin Han Hasan, M. Shahnaz Ke, Lu Patel, Jayshil J. Stoppe, Christian Heyland, Daren K. Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
description	BackgroundA recent landmark randomized controlled trial (RCT) in septic patients demonstrated an increased risk of death and persistent organ dysfunction with intravenous Vitamin C (IVVC) monotherapy, which represents a disparate result from previous systematic reviews and meta-analyses (SRMA). We performed an updated SRMA of IVVC monotherapy to summarize and explore heterogeneity across current trials and conduct trial sequential analysis (TSA) to guard against type-I or type-II statistical errors.MethodsRCTs evaluating IVVC in adult critically ill patients were included. Four databases were searched from inception to 22 June 2022 without language restrictions. The primary outcome was overall mortality. Random effect meta-analysis was performed to estimate the pooled risk ratio. TSA for mortality was performed using the DerSimonian-Laird random effect model, alpha 5%, beta 10%, and relative risk reduction (RRR) of 30%, 25%, and 20%.ResultsWe included 16 RCTs (n = 2130). IVVC monotherapy is associated with significant reduction in overall mortality risk ratio (RR) 0.73, 95% confidence interval (CI) 0.60-0.89; p = 0.002; I-2 = 42%]. This finding is supported by TSA using RRR of 30% and 25%, and sensitivity analysis using fixed-effect meta-analysis. However, the certainty of our mortality finding was rated low using GRADE due to the serious risk of bias and inconsistency. In a priori subgroup analyses, we found no differences between single vs multicenter, higher (>= 10,000 mg/day) vs lower dose and sepsis vs non-sepsis trials. Post-hoc, we found no differences in subgroup analysis of earlier (< 24 h) vs delayed treatment, longer (> 4 days) vs shorter treatment duration, and low vs other risk of bias studies. IVVC may have the greatest benefit in trials that enrolled patients above (i.e., > 37.5%; RR 0.65, 95% CI 0.54-0.79) vs below (i.e., <= 37.5%; RR 0.89, 95% CI 0.68-1.16) median control group mortality (test for subgroup differences: p = 0.06), and TSA supported this.ConclusionsIVVC monotherapy may be associated with mortality benefits in critically ill patients, particularly in patients with a high risk of dying. Given the low certainty of evidence, this potentially life-saving therapy warrants further studies to identify the optimal timing, dosage, treatment duration, and patient population that will benefit most from IVVC monotherapy.PROSPERO Registration ID: CRD42022323880. Registered 7th May 2022.
format	Article
author	Lee, Zheng-Yii Ortiz-Reyes, Luis Lew, Charles Chin Han Hasan, M. Shahnaz Ke, Lu Patel, Jayshil J. Stoppe, Christian Heyland, Daren K.
author_facet	Lee, Zheng-Yii Ortiz-Reyes, Luis Lew, Charles Chin Han Hasan, M. Shahnaz Ke, Lu Patel, Jayshil J. Stoppe, Christian Heyland, Daren K.
author_sort	Lee, Zheng-Yii
title	Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
title_short	Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
title_full	Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
title_fullStr	Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
title_full_unstemmed	Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
title_sort	intravenous vitamin c monotherapy in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
publisher	Springer Science and Business Media Deutschland GmbH
publishDate	2023
url	http://eprints.um.edu.my/38456/
_version_	1816130399030476800
score	13.235796

Intravenous vitamin C monotherapy in critically ill patients: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

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