Corticosteroid therapy for coronavirus disease 2019-related acute respiratory distress syndrome: a cohort study with propensity score analysis

Abstract

Background The impact of corticosteroid therapy on outcomes of patients with coronavirus disease 2019 (COVID-19) is highly controversial. We aimed to compare the risk of death between COVID-19-related ARDS patients with corticosteroid treatment and those without. Methods In this single-center retrospective observational study, patients with ARDS caused by COVID-19 between January 20, 2020, and February 24, 2020, were enrolled. The primary outcome was 60-day in-hospital death. The exposure was prescribed systemic corticosteroids or not. Time-dependent Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for 60-day in-hospital mortality. Results A total of 382 patients [60.7 ± 14.1 years old (mean ± SD), 61.3% males] were analyzed. The median of sequential organ failure assessment (SOFA) score was 2.0 (IQR 2.0–3.0). Of these cases, 94 (24.6%) patients had invasive mechanical ventilation. The number of patients received systemic corticosteroids was 226 (59.2%), and 156 (40.8%) received standard treatment. The maximum dose of corticosteroids was 80.0 (IQR 40.0–80.0) mg equivalent methylprednisolone per day, and duration of corticosteroid treatment was 7.0 (4.0–12.0) days in total. In Cox regression analysis using corticosteroid treatment as a time-varying variable, corticosteroid treatment was associated with a significant reduction in risk of in-hospital death within 60 days after adjusting for age, sex, SOFA score at hospital admission, propensity score of corticosteroid treatment, comorbidities, antiviral treatment, and respiratory supports (HR 0.42; 95% CI 0.21, 0.85; p = 0.0160). Corticosteroids were not associated with delayed viral RNA clearance in our cohort. Conclusion In this clinical practice setting, low-dose corticosteroid treatment was associated with reduced risk of in-hospital death within 60 days in COVID-19 patients who developed ARDS.

A Differential Therapeutic Consideration for use of Corticosteroids According to Established COVID-19 Clinical Phenotypes in Critically Ill Patients

“…First, although phenotypes were found to be generalizable in our population (after validation), risk factors and characteristics that pre-de ned these clinical phenotypes were derived initially from data at ICU admission of a multicenter observational study in Spain. However, at the same time these risk factors are similar to those that have been reported by other investigators [38][39][40][41][42][43][44][45][46][47] which suggests its applicability to other populations. Despite this, our phenotypes should be validated into other critical patient populations to assess reproducibility and cross-application.…”

Effects of Methylprednisolone on Ventilator-Free Days in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome and COVID-19: A Retrospective Study

“…However, in the CoDEX trial, dexamethasone was used at a high dose (20 mg daily for five days, and 10 mg daily for the other five days). In our study, methylprednisolone was used at a lower dose (median dose of 1mg•kg-1 daily for a median duration of 5 days), consistent with the previous publications on COVID-19 patients with methylprednisolone treatment [19,26,27]. However, the optimal dose and duration of methylprednisolone treatment in patients with COVID-19 ARDS remain unknown and need further investigations.…”

“…In addition, association with mortality was observed for patients who received dexamethasone (3 trials), but not for hydrocortisone (3 trials) or methylprednisolone (1 trial). Reports on the efficacy of methylprednisolone in ARDS patients with COVID-19 are conflicting [ 26 , 27 ]. In a randomized controlled trial that included patients with COVID-19 pneumonia, methylprednisolone treatment was not associated with improved mortality [ 26 ].…”

“…In a randomized controlled trial that included patients with COVID-19 pneumonia, methylprednisolone treatment was not associated with improved mortality [ 26 ]. In a recent observational study, methylprednisolone was associated with a reduced risk of death within 60 days in COVID-19 patients with ARDS [ 27 ]. However, most of these studies did not focus on mechanically ventilated patients.…”

Corticosteroids for COVID-19 Therapy: Potential Implications on Tuberculosis

“…The benefits of CST as adjuvant therapy have been reiterated by several independent research that favored its use for COVID-19 patients with ARDS. The administration of methylprednisolone, dexamethasone, hydrocortisone, and prednisone either orally or intravenously was reported to lower the death rate of COVID-19 patients with ARDS [ 39 ]. Reports of three different trials and metanalysis showed the beneficial effects of CST therapy in treating ARDS-associated with COVID-19 patients.…”