The role of corticosteroids in the management of critically ill patients with coronavirus disease 2019 (COVID-19): A meta-analysis

Abstract

Objective: There are no controlled studies on the role of systemic corticosteroids (CS) in patients with coronavirus disease 2019 (COVID-19). In the absence of high-quality evidence, understandably the recommendations from various organizations are cautious. Several randomized controlled trials are underway but shall take time to conclude. We therefore undertook a meta-analysis to ascertain the role of CS in the management of critically ill patients with COVID-19. Data Sources: Electronic databases, including Pubmed, Cochrane library and Embase, were searched, using the keywords of interest and the PICO search technique, from inception to 12th April 2020. Study Selection: Studies highlighting the use of CS in coronavirus infection with severe acute respiratory syndrome (SARS), Middle East Respiratory Syndrome (MERS) and COVID-19 were selected based on pre-determined inclusion criteria. Data extraction: Data was extracted into an excel sheet and transferred to comprehensive meta-analysis software version 3, Biostat Inc., Englewood, NJ, USA, for analysis. Data synthesis: Five studies with SARS-CoV-2 infection were included in the meta-analysis. The rate ratio (RR) for mortality in patients with SARS-CoV-2 infection was 1.26 (95% CI: 0.96-1.65, I2: 74.46), indicating lack of benefit of CS therapy on mortality in critically ill patients with COVID-19. The RR for mortality on analysis of the three studies that particularly reported on patients with significant pulmonary compromise secondary to SARS-CoV-2 infection was neutral (RR: 0.91, 95% CI: 0.63-1.33, I2: 63.38). Conclusions: The use of CS in critically ill patients with COVID-19 did not improve or worsen mortality. Pending further information from controlled studies, CS can be used in critically ill patients with COVID-19 with critical illness related corticosteroid insufficiency and moderate to severe ARDS without the risk of increased mortality.

Efficacy of various treatment modalities for nCOV‐2019: A systematic review and meta‐analysis

“…Use of corticosteroid treatment was found to be associated with higher mortality (RR 2.11; 95%CI 1.13 to 3.94) in nCOV-2019 and SARS patients in a meta-analysis of 15 studies conducted by Yang et al, 68 while three meta-analyses found that corticosteroid use did not worsen/improve mortality in patients with nCOV-2019, SARS-Cov and MERS-Cov. [69][70][71] Further, the meta-analysis by Li et al 70 also observed a delayed time to virus clearance in the corticosteroid group compared to controls (MD 3.78; 95%CI 1.16 to 6.41). The findings of our meta-analysis are also in line with the previously published meta-analyses on corticosteroids.…”

Coronavirus disease 2019: investigational therapies in the prevention and treatment of hyperinflammation

“…Some studies have found associations between glucocorticoids use and increased risk of mortality or worsened clinical courses [151][152][153][154]. Other studies have suggested that glucocorticoids use was associated with reduced mortality risk or better clinical courses, and others still have found no association between glucocorticoids use and outcomes [32,[153][154][155][156][157][158][159][160] [- [161][162][163][164]. In the COVID-19 Global Rheumatology Alliance physician-reported registry, chronic use of prednisone dose ≥10 mg/day was associated with higher odds of hospitalization [123].…”

Efficacy of corticosteroids in non-intensive care unit patients with COVID-19 pneumonia from the New York Metropolitan region

“…A meta-analysis of randomized clinical trials suggested corticosteroid could reduce mortality and need for mechanical ventilation in patients with severe community-acquired pneumonia, irrespective of bacterial or viral etiology [ 16 , 17 ]. On the contrary, another meta-analysis showed higher mortality among patients receiving corticosteroids [ 18 ]. However, this meta-analysis included patients with SARS, MERS, COVID-19, and had high heterogeneity.…”

“…However, this meta-analysis included patients with SARS, MERS, COVID-19, and had high heterogeneity. A subgroup analysis from the same study reported no significant difference in mortality between two cohorts when included only COVID-19 patients [18], suggesting corticosteroids may not be harmful in these patients. We assume studies that showed higher or no difference in mortality with corticosteroid were critically ill with ARDS, on mechanical ventilation, and they might have passed the point where adverse outcomes could be modified by corticosteroid.…”