Current best evidence for clinical care (more info)
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.
| Discipline / Specialty Area | Score |
|---|---|
| Hospital Doctor/Hospitalists | |
| Internal Medicine | |
| Intensivist/Critical Care | |
| Respirology/Pulmonology | |
| Infectious Disease | |
This is an important study that showed possible detrimental effect of corticosteroids in patients with COVID-19 with preserved respiratory function. Certainly, it would be very helpful to analyze if particular steroid or dosage or route of administration would affect mortality or recovery of respiratory function.
The results are very relevant to the clinical management of patients with COVID-19 and they point to an urgent need for more studies.
This is a systematic review of corticosteroids in the management of patients with COVID 19 and hypoxemic respiratory failure. There were several randomized controlled trials that met inclusion criteria, but the review is dominated by the RECOVERY trial. There was an assessment of the composite benefit as well as risk of bias using the Cochrane bias assessment tool. There was a possible increased risk for mortality in patients not requiring oxygen, otherwise the benefit was positive. The RECOVERY trial with its dexamethasone dose of 6 mg is probably the best assessment of a practice-changing use of corticosteroids in this setting.
This is a very interesting study. It's difficult to draw definitive conclusions on the data presented.
Do we need more metanalyses than RCTs?