Corticosteroids Improve COVID-19 Recovery, Now Are Recommended Therapy
Initially in the COVID-19 pandemic, the search for effective therapies somewhat overlooked the possibility of corticosteroids. The reason was that the drugs appeared to present more risks than benefits in earlier coronaviruses such as SARS and MERS. With new randomized clinical trials, the situation has changed, however, and corticosteroids now are recommended treatment. Here is more information.
PITTSBURGH – As the COVID-19 pandemic began, recommendations on using corticosteroids in patients with acute respiratory distress syndrome were weak, at best. One reason is that, in other viral pneumonias, especially severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), it appeared that corticosteroids could be impairing host response to SARS-CoV-2 and even could be increasing mortality in influenza-related pneumonia.
Despite that, several clinical trials sought to balance potential benefits of corticosteroids with potential harms associated with the drugs.
A recent issue of JAMA features three multicenter RCTs that assessed corticosteroid therapy in critically ill patients with COVID-19, as well as the World Health Organization prospective meta-analysis. All three trials halted enrollment in June 2020 after a press release from the Randomized Evaluation of COVid-19 thERapY (RECOVERY) Trial on dexamethasone determined that the drug reduced deaths by one-third in ventilated patients (rate ratio 0.65 [95% confidence interval 0.48 to 0.88]; p=0.0003) and by one fifth in other patients receiving oxygen only (0.80 [0.67 to 0.96]; p=0.0021). University of Oxford Investigators found no benefit among those patients who did not require respiratory support (1.22 [0.86 to 1.75]; p=0.14).
One U.S. study published in JAMA was REMAP-CAP. It was among seven randomized control trials to test corticosteroids in critically ill COVID-19 patients. An analysis combining all the trial data reinforces the June results of the UK RECOVERY trial, which found the steroid dexamethasone reduced deaths by 29% in ventilated COVID-19 patients.
"It is relatively rare in medicine that you find drugs where the evidence of their effectiveness in saving lives is so consistent," explained lead author Derek Angus, MD, MPH, professor and chair of the Department of Critical Care Medicine at the University of Pittsburgh and chief health care innovation officer at UPMC. "This is, in many respects, the single clearest answer we've had so far on how to manage terribly ill COVID-19 patients. People on ventilators or oxygen and under intensive care should definitely be given corticosteroids."
Between March and June, the REMAP-CAP corticosteroid trial randomized 403 adult COVID-19 patients admitted to an intensive care unit to receive the steroid hydrocortisone or no steroids at all. The trial found a 93% probability that giving patients a seven-day intravenous course of hydrocortisone would result in better outcomes than not giving the steroid. The results were consistent across age, race and sex.
Corticosteroids also appear to be associated with benefit among critically ill patients with COVID-19 whether they are receiving mechanical ventilation or oxygen without mechanical ventilation, according to the research.