Is Vitamin C The Answer?

Posted by Jeremy Windsor on Apr 22, 2020

I was brought up to take a large dose of Vitamin C if I developed an infection. Thinking about it, I probably still do! Don't you? In the last couple of years Vitamin C has been increasingly used in critical care to treat patients with sepsis and septic shock. This is largely the result of an eye catching study published in Chest that showed a combination of Vitamin C, hydrocortisone and thiamine (Vitamin B1), reduced mortality in sepsis from 40.4% to 8.5%. Despite a long list of methodological issues, including small sample size and a lack of randomization, many critical care physicians were persuaded to use Vitamin C to treat patients with sepsis and septic shock. But was this the right thing to do?

A recently published study in JAMA paints a very different picture. The VITAMINS trial studied a group of 216 patients with septic shock and treated them with standard antibiotics and either Vitamin C, hydrocortisone and thiamine (Vitamin B1) or hydrocortisone alone. Clinically, the addition of Vitamins B1 and C made no difference to outcomes such as time of survival and 90 day mortality. This shouldn't come as a surprise. As an editorial in the same issue of JAMA explained, since the first research in Chest was published, 10 out of 12 studies had been unable to find a good reason for giving Vitamin C, either alone or in combination with any other drug.

Vitamin C deficiency is a common finding in septic patients. Indeed, those with the lowest plasma concentrations often suffer the greatest degree of organ failure. This may be due to the fact that Vitamin C plays important parts in a number of responses that the body makes to infection. Therefore it's not surprising to hear that many believe there's a role for Vitamin C in the treatment of sepsis and septic shock. However a good deal of research doesn't back this up!

Of course, this isn't the end of the story. A further 37 trials looking at the effect of Vitamin C on sepsis and septic shock are planned. Such a number reflects the deeply held belief that surely a dose of Vitamin C does us some good. After all, what harm can it do? But before you prescribe it, take a moment to read the conclusion of the earlier editorial,

Use of high-dose Vitamin C in combination or alone “just in case” or as a “measure of last resort", aside from providing no survival benefits, could have several other potential consequences, including diverting funding from much needed research into examining sepsis mechanisms and diagnostics; stifling the development of other sepsis therapies; perpetuating false hopes for patients, families, and clinicians; and delaying proven lifesaving therapies such as prompt initiation of antibiotic therapy. 

For those of us who practise mountain medicine, the key is to identify sepsis and septic shock, administer an appropriate antibiotic and evacuate to a medical facility. Don't rely upon Vitamin C to make a difference!

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1 thought on “Is Vitamin C The Answer?

Piotr Szawarski commented 1 year ago
Dear Jeremy, How interesting that you should bring up the question of vitamin C. Ok, I admit, that without any trace of science behind it, I am taking it daily now. There is folk wisdom behind it and one needs a degree of humility as well as critical approach to science to balance one's decisions. We cannot pretend to know everything. I cannot see harm in taking it. Now, VITAMINS study had a problem of having a potent steroid in both intervention and control group that would crowd out any effects of a less potent intervention. Secondly enrolling patients when they are already critically unwell is perhaps too late to see an effect of something such as a vitamin. I think the question should be do people who take regular vitamin C are less likely to need critical care or develop sepsis or ARDS. You may be aware also of CITRIS-ALI RCT again published in JAMA (JAMA 2019;322(13):1261-70). I actually heard the presentation on this trial at the ESICM Congress in Berlin and it was... fishy (without there being any omega-3 involved). First supernormal amounts of vitamin C were given IV... (always a strange idea) and secondly even though main outcome measures were change in organ failure as assessed by SOFA and changes in inflammatory markers, the speaker concentrated on mortality benefit observed with Vitamin C - even though this was not an outcome defined by trial design. Exciting, yes - scientific, no. So to conclude - is vitamin C the golden bullet for terrible illnesses other than scurvy? Not sure. Certainly not in the way we try to use it. Should we take it? Maybe? Should we give it to patients...? No evidence there, but repletion of perceived nutritional deficiency is a good idea before commencement of re-feeding.

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