The Pulse - May 2025

In this monthly edition, we examine 3 practice changing studies from May 2025.

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1. Time to STASH Fixed Dose Steroids for Alcoholic Hepatitis

   A long-standing standard may need a reboot: the STASH trial found that tapering corticosteroids in severe alcohol-associated hepatitis led to significantly fewer infections (20% vs. 33%, NNT = 8) and rehospitalizations compared to the traditional fixed-dose regimen. In this RCT of 254 patients (mean age 41), both groups started at 40 mg of prednisolone daily, but the taper group decreased the dose weekly. Non-responders by Lille score at day 7 had steroids discontinued. Mortality and AKI rates were similar, but infection-related morbidity favored tapering. Despite study limitations (unblinded design, mostly male cohort), STASH supports a shift toward tapering steroids to reduce complications and improve care efficiency in this high-risk population. Kulkarni AV et al. Am J Gastroenterol 2025 Mar.

   Study Type: multicenter randomized, unblinded clinical trial of 254 patients with severe alcohol-associated hepatitis (MELD ≥21 or MDF ≥32) who were randomized to standard fixed prednisolone dose (40 mg/d) for 4 weeks or 40 mg/d tapered by 10 mg/d every week over 4 weeks

   Link: https://doi.org/10.14309/ajg.0000000000003416

2. Masking the Problem—Or Solving It? NIV in the Asthma ICU

   Noninvasive ventilation (NIV) is inching closer to legitimacy in the management of acute asthma exacerbations—though it’s not quite ready for a guideline coronation. A new systematic review analyzed 8 RCTs and 5 observational studies comparing NIV plus standard therapy to standard therapy (supplemental O2 + bronchodilators + steroids) alone. While the RCTs were underpowered and didn’t demonstrate significant effects on mortality or intubation, a large observational study (n > 25,000) showed a notable mortality benefit (RR 0.56) and fewer intubations (RR 0.55). Clinicians still need to tread carefully—this isn’t a green light for everyone gasping for air—but for alert, cooperative patients in moderate distress, early NIV may be a reasonable tool to add to your arsenal. For more severe cases or those with hypercapnia, standard of care remains intubation. Homer-Bouthiette C and Wilson KC. Ann Am Thorac Soc 2025 May.

   Study Type: Systematic review of 8 RCTs and 5 observational studies

   Link: https://doi.org/10.1513/AnnalsATS.202407-799OC

3. A DOAC Face-Off Without the Bloodshed

   In a large observational study comparing oral anticoagulants in VTE management, apixaban edged out its competitors—rivaroxaban and warfarin—in both efficacy and safety. Apixaban was associated with the lowest rates of VTE recurrence and major bleeding during a median follow-up of six months, while all-cause mortality remained similar across groups. These findings bolster the growing body of evidence favoring apixaban's safety profile and now hint at a modest efficacy advantage over rivaroxaban. While head-to-head RCTs remain elusive, this real-world data gives clinicians more reason to lean toward apixaban—assuming insurance and dosing convenience cooperate. After all, the best anticoagulant is the one the patient will actually take (and can afford). Bea S et al. JAMA Intern Med 2025 May.

   Study Type: observational, population-based cohort study of 163,593 patients (from databases with Medicare and 2 commercial insurances) receiving anticoagulation for VTE
   Link: https://doi.org/10.1001/jamainternmed.2025.1109

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