COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Treatment Horby P, Lim WS, Emberson JR, et al. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med. 2020 Jul 17. doi: 10.1056/NEJMoa2021436.
Abstract

BACKGROUND: Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death.

METHODS: In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison.

RESULTS: A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55).

CONCLUSIONS: In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.).

Ratings
Discipline / Specialty Area Score
Respirology/Pulmonology
Hospital Doctor/Hospitalists
Internal Medicine
Infectious Disease
Intensivist/Critical Care
Comments from MORE raters

Infectious Disease rater

This article has already been judged and discussed extensively everywhere. Its novelty, as presented to the press by its authors, is inferior to what an uninitiated reader would suspect. In the past, large studies have been done about the impact of steroids in critically ill infectious disease patients. The outcome in the specific settings was far from surprising. A major issue in the study remains the high mortality, even in non-ventilated patients.

Intensivist/Critical Care rater

Well done with important results. This will impact the worldwide care of patients with COVID.

Internal Medicine rater

This information needs to be updated often.

Internal Medicine rater

Steroid use in Covid-19 was very controversial at the beginning with the initial limited studies showing enhanced viral replication. Steroids were not used in Covid-19 patients in February and March. Clinically, I noticed many of my Covid-19 patients in the ICU who were already on steroids prior to Covid-19 with shock and on ventilator did recover early when stress doses of steroids were used. Cytokine release syndrome responded well to steroids when we used steroids starting day 5-10. This well done study was very much anticipated. It provides specific doses and shows improvement in Covid-19 patients. As an Intensivist working with very sick Covid patients, I knew steroids work but I needed evidence and an RCT to share with my colleagues and for use in a second wave.

Respirology/Pulmonology rater

My academic team followed the Recovery Trial's data from initial publication of the protocol to the press release and then the BioArxiv pre-pub paper. Once the pre-pub paper was released with appropriate analysis in it, we immediately changed our enterprise-wide protocols (3M patient population) to use dexamethasone in any COVID patient admitted to the hospital and in need of oxygen. For COVID(+) patients not on oxygen, the data is equivocal as to whether dexamethasone helps. We leave that decision up to the individual provider.

Respirology/Pulmonology rater

In the current era of uncertainty with treatment of COVID disease, this is a good evaluation of the use of steroids in coronavirus infection. The division of patients into severity of illness based on mechanical ventilation need vs oxygen need vs no O2 requirement is an added benefit as not everyone was helped with the use of exogenous steroids.