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COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

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Treatment Ye Z, Wang Y, Colunga-Lozano LE, et al. Efficacy and safety of corticosteroids in COVID-19 based on evidence for COVID-19, other coronavirus infections, influenza, community-acquired pneumonia and acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ. 2020 Jul 6;192(27):E756-E767. doi: 10.1503/cmaj.200645. Epub 2020 May 14.
Abstract

BACKGROUND: Very little direct evidence exists on use of corticosteroids in patients with coronavirus disease 2019 (COVID-19). Indirect evidence from related conditions must therefore inform inferences regarding benefits and harms. To support a guideline for managing COVID-19, we conducted systematic reviews examining the impact of corticosteroids in COVID-19 and related severe acute respiratory illnesses.

METHODS: We searched standard international and Chinese biomedical literature databases and prepublication sources for randomized controlled trials (RCTs) and observational studies comparing corticosteroids versus no corticosteroids in patients with COVID-19, severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS). For acute respiratory distress syndrome (ARDS), influenza and community-acquired pneumonia (CAP), we updated the most recent rigorous systematic review. We conducted random-effects meta-analyses to pool relative risks and then used baseline risk in patients with COVID-19 to generate absolute effects.

RESULTS: In ARDS, according to 1 small cohort study in patients with COVID-19 and 7 RCTs in non-COVID-19 populations (risk ratio [RR] 0.72, 95% confidence interval [CI] 0.55 to 0.93, mean difference 17.3% fewer; low-quality evidence), corticosteroids may reduce mortality. In patients with severe COVID-19 but without ARDS, direct evidence from 2 observational studies provided very low-quality evidence of an increase in mortality with corticosteroids (hazard ratio [HR] 2.30, 95% CI 1.00 to 5.29, mean difference 11.9% more), as did observational data from influenza studies. Observational data from SARS and MERS studies provided very low-quality evidence of a small or no reduction in mortality. Randomized controlled trials in CAP suggest that corticosteroids may reduce mortality (RR 0.70, 95% CI 0.50 to 0.98, 3.1% lower; very low-quality evidence), and may increase hyperglycemia.

INTERPRETATION: Corticosteroids may reduce mortality for patients with COVID-19 and ARDS. For patients with severe COVID-19 but without ARDS, evidence regarding benefit from different bodies of evidence is inconsistent and of very low quality.

Ratings
Discipline / Specialty Area Score
General Internal Medicine-Primary Care(US)
Hospital Doctor/Hospitalists
Internal Medicine
Family Medicine (FM)/General Practice (GP)
Pediatric Emergency Medicine
Public Health
Emergency Medicine
Pediatric Hospital Medicine
Infectious Disease
Comments from MORE raters

Emergency Medicine rater

This is not too significant in the emergency room setting vs. the ICU.

Emergency Medicine rater

Although this systematic review is as up-to-date as possible, the conflicting results from RCT and cohort studies, the relative lack of evidence, and the use of indirect evidence from other conditions make it impossible to draw any conclusion. More study is urgently needed.

Family Medicine (FM)/General Practice (GP) rater

Good summary of the evidence.

General Internal Medicine-Primary Care(US) rater

Like the vast majority COVID-19 literature, this gives little solid information. When one says corticosteroids may reduce mortality for patients with COVID-19 and ARDS, the authors could just as easily said "may not" reduce mortality.

Infectious Disease rater

The evidence that corticosteroids may reduce mortality in patients with COVID-19 and ARDS is only indirect. It does not correlate and is contrary to direct evidence provided in figure 2.

Internal Medicine rater

As a general internist, I find this summary supports the prevailing view on COVID19. Corticosteroids have not been shown in RCTs to meaningfully impact clinical outcomes in SARS, MERS, or COVID-19. The rating of evidence was low for most outcomes, with the wide confidence intervals further contributing to ambiguity regarding any perceived efficacy.

Public Health rater

There is very low quality evidence. The newsworthiness list does not include this important evaluation as a criterion.

Public Health rater

This is important information. Steroids reduce mortality in COVID-19 when it is complicated with ARDS, but they could be deleterious in patients without severe respiratory distress.