Pulse versus nonpulse steroid regimens in patients with coronavirus disease 2019: A systematic review and meta‐analysis

Khokher, Waleed; Beran, Azizullah; Iftikhar, Saffa; Malhas, Saif‐Eddin; Srour, Omar; Mhanna, Mohammed; Bhuta, Sapan; Patel, Dipen; Kesireddy, Nithin; Burmeister, Cameron; Borchers, Elizabeth; Assaly, Ragheb; Safi, Fadi

doi:10.1002/jmv.27824

Cited by 6 publications

(3 citation statements)

References 28 publications

(119 reference statements)

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“…Indeed, regardless of steroid dose, there was no improvement among iMV-free patients. Similar to our results, prior studies reported that appropriate selection of patients to be treated with high-dose methylprednisolone is necessary to optimise the riskbenefit balance of steroids for acute COVID-19 patients [7,[25][26][27][28].…”

Section: Discussionsupporting

confidence: 89%

Intravenous methylprednisolone pulse therapy and the risk of in-hospital mortality among acute COVID-19 patients: Nationwide clinical cohort study

et al. 2023

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Background Steroids are widely used to modulate the inflammatory reactions associated with coronavirus disease 2019 (COVID-19); however, the optimal upper limit dose of steroid use for acute COVID-19 care remains unclear and currently available data may suffer from a time-dependent bias of no effectiveness or reversed causation given the desperate situation of treatment during this pandemic. Accordingly, the aim of this study was to elucidate the impact of intravenous pulse therapy with methylprednisolone (500 mg or greater per day) on the risk of in-hospital mortality among patients with COVID-19 by controlling for time-dependent bias. Methods We performed a prospective cohort study with 67,348 hospitalised acute COVID-19 patients at 438 hospitals during 2020–2021 in Japan. The impact of intravenous methylprednisolone pulse therapy on the risk of in-hospital mortality was examined based on hazard ratios (HRs) and 95% confidence intervals (95% CIs), with stratification according to the status of invasive mechanical ventilation (iMV). Time-dependent bias was controlled for in a marginal structural model analysis, with reference to patients without methylprednisolone therapy. Results During the study period, 2400 patients died. In-hospital mortality rates of iMV-free patients without or with methylprednisolone pulse therapy were 2.3% and 19.5%, and the corresponding values for iMV-receiving patients were 24.7% and 28.6%, respectively. The marginal structural model analysis showed that intravenous pulse therapy with methylprednisolone was associated with a lower risk of in-hospital mortality among patients receiving-iMV (HR 0.59; 95% CI 0.52–0.68). In contrast, pulse therapy with methylprednisolone increased the risk of in-hospital mortality among iMV-free patients (HR 3.38; 95% CI 3.02–3.79). The benefits of pulse therapy for iMV-receiving patients were greater than in those treated with intermediate/higher doses (40–250 mg intravenously) of methylprednisolone (HR 0.80; 95% CI 0.71–0.89). Conclusion The results of our study suggest that intravenous methylprednisolone showed dose–response efficiencies, and pulse therapy may benefit critically ill patients with acute COVID-19, such as those requiring iMV.

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Section: Discussionsupporting

confidence: 89%

Intravenous methylprednisolone pulse therapy and the risk of in-hospital mortality among acute COVID-19 patients: Nationwide clinical cohort study

et al. 2023

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“…Although corticosteroid therapy was administered to pre-ICU patients a median of six days from symptom onset at an oxygen saturation-to-fraction of inspiratory oxygen ratio of 404.2 (equivalent to an oxygen saturation of 85% while the patient was breathing ambient air at rest), it did not prevent ICU admission in this study. A meta-analysis reported that, compared to non-pulse dose steroids, pulse dose steroids are associated with a similar mortality rate and need for endotracheal intubation ( 17 ). Recently, a randomized control trial reported that no significant differences between pulse methylprednisolone and placebo arms were observed for admission to the ICU with orotracheal intubation or death ( 18 ).…”

Section: Discussionmentioning

confidence: 99%

Timeline of Oxygen Demand in Patients with COVID-19 Pneumonia

et al. 2022

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Objective In patients with coronavirus disease 2019 , understanding the timeline of oxygen demand and severe respiratory failure, such as intensive-care unit (ICU) admission, may clarify the therapeutic window when home-care treatment is possible and help determine the timing of treatment in hospitalized patients to improve the respiratory status. We examined the timeline of respiratory status in hospitalized patients with moderate-to-severe COVID-19 in terms of oxygen demand and ICU admission. Methods We retrospectively assessed all patients with COVID-19 who were admitted to our hospital between February 2020 and February 2021 and required supplemental oxygen. This study included 66 patients who were transferred to the ICU (ICU patients) and 144 patients who were not transferred to the ICU (non-ICU patients). Results In the total cohort, the median duration from symptom onset to the need for supplemental oxygen was 8 (interquartile range [IQR] 6-10) days. This duration was significantly shorter in ICU patients than in non-ICU patients [8 (IQR 6-9) vs. 9 (IQR 6-10) days, p = 0.02]. The median duration from symptom onset to ICU admission was 9 (IQR 8-11) days in severely ill patients. The median duration from the initiation of supplemental oxygen to ICU admission was 1.0 (IQR 1-2.75) days. Only 2 of 66 patients (3.0%) were admitted to the ICU six days or later after initiation of supplemental oxygen. Conclusions Physicians should carefully monitor each patient's condition after eight days from symptom onset. New therapies and their early administration are needed to reduce the frequency of respiratory failure in COVID-19 patients.

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“…However, many centres, particularly in India and other Asian countries, started using higher doses including pulse dose of steroids for almost all hospitalised patients whether hypoxaemic or non-hypoxaemic that could be an underlying cause of increased mortality in the disease. [ 3 ]…”

mentioning

confidence: 99%

Steroid treatment for COVID-19: Suitable dose and patients

Hashim,

Nath,

Tripathy

2023

Lung India

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Pulse versus nonpulse steroid regimens in patients with coronavirus disease 2019: A systematic review and meta‐analysis

Cited by 6 publications

References 28 publications

Intravenous methylprednisolone pulse therapy and the risk of in-hospital mortality among acute COVID-19 patients: Nationwide clinical cohort study

Intravenous methylprednisolone pulse therapy and the risk of in-hospital mortality among acute COVID-19 patients: Nationwide clinical cohort study

Timeline of Oxygen Demand in Patients with COVID-19 Pneumonia

Steroid treatment for COVID-19: Suitable dose and patients

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