Current best evidence for clinical care (more info)
BACKGROUND: Although almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients.
METHODS: In this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/kg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8).
RESULTS: There were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040).
CONCLUSION: In hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone.
TRIAL REGISTRATION: The trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1 ).
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This study describes an important difference in clinical outcomes of COVID-19 patients with respiratory failure when treated with a high dose of 6M prednisolone (2 mg/kg/day) as compared to the standard 6 mg of dexamethasone (after RECOVERY). While the authors make an emphasis on the steroid (presumably with a better pulmonary access), it is noteworthy that the steroid dose is about 4 times higher for the 6MP group. Other sources of concern are 1) the actual degree of blindness (no placebo control is included and the tapering protocol was different for both steroids. 2) the important differences for such a small study (n=86 while RECOVERY trial recruited > 2000 patients). Other studies did not find better outcomes for 6MP. The findings of this must be replicated in other trials before changes in the standard of care are made.
I read this article with interest. As a practicing hospitalist, I deal with COVID-19 patients every day. This study provides enough evidence to broaden the usage of methylprednisolone in COVID-19 patients. Unfortunately, it's still unclear whether intervention group did better because of higher dose of steroids or due to intrinsic characteristics of methylprednisolone.
Based on this study results in hospitalized hypoxic COVID-19 patients, methylprednisolone (2 mg/kg/day) demonstrated better results compared to dexamethasone (6 mg/kg/day). Based on our practice, always pay attention to patients' blood glucose level, when corticosteroid treatment is essential (especially in whom need ICU care or intubated).