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Corticosteroids for Patients With Coronavirus Disease 2019 (COVID-19) With Different Disease Severity: A
Laura Pasin1, Paolo Navalesi2, Alberto Zangrillo3
1Institute of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria di Padova, Padova, Italy.
Insights
Corticosteroids reduce mortality in severe COVID-19 patients requiring mechanical ventilation but increase risk in those not needing oxygen. Further trials are needed for global implementation.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Pharmacology
Background:
- The use of corticosteroids for treating 2019-nCoV (novel coronavirus 2019) infection remains a subject of debate.
- Recent large randomized clinical trials (RCTs) and meta-analyses have focused on intensive care unit (ICU) patients with coronavirus disease (COVID-19).
Purpose of the Study:
- To conduct a meta-analysis of RCTs evaluating corticosteroid therapy in patients with COVID-19 across different disease severities.
- To assess the effect of corticosteroids on survival rates in hospitalized patients with COVID-19.
Main Methods:
- A systematic meta-analysis of randomized clinical trials (RCTs) involving adult patients with acute hypoxemic failure due to 2019-nCoV infection.
- Included studies compared corticosteroid administration against any control group.
- The primary endpoint for all studies was the mortality rate.
Main Results:
- Five RCTs comprising 7,692 patients were analyzed.
- Overall mortality was significantly lower in patients treated with corticosteroids (26%) compared to controls (28%) (RR 0.89, p=0.003).
- Beneficial effects were observed in mechanically ventilated patients (RR 0.85, p=0.05), with a reduced need for mechanical ventilation. However, corticosteroids increased mortality in patients not requiring oxygen (17% vs 13%, RR 1.23, p=0.05).
Conclusions:
- Corticosteroids can be considered for severe, critically ill COVID-19 patients.
- Corticosteroid use should be avoided in COVID-19 patients not requiring oxygen therapy.
- Further research and clinical trials are essential before widespread implementation of corticosteroid treatment for COVID-19.
Objectives:
Efficacy and safety of corticosteroids in patients with 2019-nCoV (novel coronavirus 2019) infection still are debated. Because large randomized clinical trials (RCTs) and a well-conducted meta-analysis on the use of corticosteroids, focused on patients with coronavirus disease (COVID-19) in intensive care units, recently were published, a meta-analysis of RCTs on corticosteroids therapy in patients with different disease severity was performed to evaluate the effect on survival.
Design:
A meta-analyses of RCTs was performed.
Setting:
Patients admitted to hospital.
Participants:
Patients with coronavirus disease.
Interventions:
Administration of corticosteroids.
Measurements And Main Results:
A search was performed for RCTs of adult patients with acute hypoxemic failure related to 2019-nCoV infection who received corticosteroids versus any comparator. The primary endpoint was mortality rate. Five RCTs involving 7,692 patients were included. Overall mortality of patients treated with corticosteroids was slightly but significantly lower than mortality of controls (26% v 28%, relative risk {RR} = 0.89 [95% confidence interval {CI} 0.82-0.96], p = 0.003). The same beneficial effect was found in the subgroup of patients requiring mechanical ventilation (RR = 0.85 [95% CI 0.72-1.00], p = 0.05 number needed to treat {NNT} = 19). Remarkably, corticosteroids increased mortality in the subgroup of patients not requiring oxygen (17% v 13%, RR = 1.23 [95% CI 1.00-1.62], p = 0.05 number needed to harm {NNH} = 29). Tests for comparison between mechanically ventilated subgroups and those not requiring oxygen confirmed that treatment with corticosteroids had a statistically significant different effect on survival. Patients treated with corticosteroids had a significantly lower risk of need for mechanical ventilation.
Conclusions:
Corticosteroids may be considered in severe critically ill patients with COVID-19 but must be discouraged in patients not requiring oxygen therapy. Urgently, further trials are warranted before implementing this treatment worldwide.
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