Current best evidence for clinical care (more info)
BACKGROUND: In the current SARS-CoV-2 pandemic, there has been worldwide debate on the use of corticosteroids in COVID-19. In the recent RECOVERY trial, evaluating the effect of dexamethasone, a reduced 28-day mortality in patients requiring oxygen therapy or mechanical ventilation was shown. Their results have led to considering amendments in guidelines or actually already recommending corticosteroids in COVID-19. However, the effectiveness and safety of corticosteroids still remain uncertain, and reliable data to further shed light on the benefit and harm are needed.
OBJECTIVES: The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of corticosteroids in COVID-19.
METHODS: A systematic literature search of RCTS and observational studies on adult patients was performed across Medline/PubMed, Embase and Web of Science from December 1, 2019, until October 1, 2020, according to the PRISMA guidelines. Primary outcomes were short-term mortality and viral clearance (based on RT-PCR in respiratory specimens). Secondary outcomes were: need for mechanical ventilation, need for other oxygen therapy, length of hospital stay and secondary infections.
RESULTS: Forty-four studies were included, covering 20.197 patients. In twenty-two studies, the effect of corticosteroid use on mortality was quantified. The overall pooled estimate (observational studies and RCTs) showed a significant reduced mortality in the corticosteroid group (OR 0.72 (95%CI 0.57-0.87). Furthermore, viral clearance time ranged from 10 to 29 days in the corticosteroid group and from 8 to 24 days in the standard of care group. Fourteen studies reported a positive effect of corticosteroids on need for and duration of mechanical ventilation. A trend toward more infections and antibiotic use was present.
CONCLUSIONS: Our findings from both observational studies and RCTs confirm a beneficial effect of corticosteroids on short-term mortality and a reduction in need for mechanical ventilation. And although data in the studies were too sparse to draw any firm conclusions, there might be a signal of delayed viral clearance and an increase in secondary infections.
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The JAMA paper and WHO reports already addressed the issue.
This is a nice metanalysis about steroid use in COVID-19. The metanalysis systematically reviewed the role of steroids using sparse and variable but robustly done studies. In general, this analysis helps confirm that steroids are often helpful in longer durations than originally expected. Additionally, as might be expected, prolonged steroid use sets up the risk for higher Abx use and other complications.
This systematic review evaluates both randomized and non-randomized evidence for steroids in COVID-19. This evidence has been reviewed and published elsewhere (including in several clinical practice guidelines). So while relevant, it is nothing new. In addition, there are a few questionable methods used (retrospective registration, post-hoc decisions about using RR vs OR, pooling randomized with non-randomized data) that further reduce the relevance of the results here.
This is news from 4 months ago and everyone has changed their practice. There have been multiple RCTs and a meta-analysis already published in JAMA, along with clinical practice guidelines. Although this meta-analysis includes observational data, the take-home message is not new.