COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

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Treatment Shuto H, Komiya K, Yamasue M, et al. A systematic review of corticosteroid treatment for noncritically ill patients with COVID-19. Sci Rep. 2020 Dec 1;10(1):20935. doi: 10.1038/s41598-020-78054-2.
Abstract

The World Health Organization (WHO) has published guidance recommending systemic corticosteroids for the treatment of patients with severe or critical COVID-19 and no corticosteroids for those with nonsevere COVID-19. Although their recommendations for critical cases were based on the results from seven randomized controlled trials (RCTs), those for noncritical cases were based on the results from only one RCT, the Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial. In search of additional evidence of corticosteroids' effect on COVID-19, we systematically reviewed controlled observational studies, besides RCTs, that assessed the impact of corticosteroid treatment on any type of mortality and/or other outcomes in noncritical patients. Of the 4037 titles and abstracts screened, we ultimately included the RECOVERY trial and five controlled observational studies using propensity score matching, (accessed on September 8, 2020). Two of the controlled observational studies assessed the association between corticosteroid treatment and in-hospital mortality, without finding statistical significance. Four of the controlled observational studies assessed corticosteroids' effect on other outcomes, demonstrating that they were associated with reduced risk of intubation in patients requiring oxygen and with longer hospitalization and viral shedding in mild or moderate cases. These results support the WHO recommendations not to use corticosteroids for nonsevere COVID-19.

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

Emergency Medicine rater

The World Health Organization currently recommends against the use of steroids in non-severe COVID-19. This systematic review and meta-analysis included RCTs or controlled observational studies evaluating the use of steroids in COVID-19. This meta-analysis included the RECOVERY trial, which found patients requiring supplemental oxygen/mechanical ventilation had reduced mortality with dexamethasone 6 mg IV or PO. Five other controlled observation studies were included. Two observational studies did not find improved survival with steroids. Four observational studies found reduced risk of intubation in patients requiring oxygen but longer hospitalization and viral shedding in mild to moderate cases. However, there was significant heterogeneity in steroid dose, duration, and timing. For those requiring oxygen/mechanical ventilation, steroids are recommended. For other patients with non-severe/mild illness, steroids are not recommended, but patients require monitoring.

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

The study confirms the current recommendation of not using steroids on mild and moderate COVID disease.

Infectious Disease rater

This is an elaborate review worth reading. The patients without a proinflammatory situation/cytokine storm do not benefit from anti-inflammatory treatment, rather there is a risk for amplifying immune paralysis. However, from the perspective of the intensive care therapist, the issue is of only limited importance because we do not primarily treat non-critically ill patients.

Infectious Disease rater

This systemic review adds to the body of evidence supporting the therapeutic use of corticosteroids in managing some groups of COVID-19 patients. The findings reinforce existing guidelines by providing additional data from controlled observational studies (accounting for confounding factors using propensity score matching) in a pragmatic manner.