Clinical question: Is early glucocorticoid therapy associated with reduced mortality or need for mechanical ventilation in hospitalized patients with SARS-CoV-2 infection?
Background: Glucocorticoids have been used as adjunctive treatment in some infections with inflammatory responses, but their efficacy in COVID-19 infections had not been entirely clear. The RECOVERY trial found a subset of patients with COVID-19 who may benefit from treatment with glucocorticoids. The ideal role of steroids in this infection, and who the subset of patients might be for whom they would benefit, is so far unclear.
Study design: Retrospective cohort analysis.
Setting: Large academic health center in New York.
Synopsis: Researchers analyzed admissions of COVID-19 positive patients hospitalized between March 11, 2020 and April 13, 2020 who did not die or become mechanically ventilated within the first 48 hours of admission. Patients treated with glucocorticoids within 48 hours of admission were compared with patients who were not treated with glucocorticoids during this time frame. In total, 2,998 patients were examined, of whom 1,806 met inclusion criteria, and 140 (7.7%) were treated with glucocorticoids within 48 hours of admission. These treated patients were more likely to have an underlying pulmonary or rheumatologic comorbidity. Early use of glucocorticoids was not associated with in-hospital mortality or mechanical ventilation in either adjusted or unadjusted models. However, if the initial C-reactive protein (CRP) was >20mg/dL, this was associated with a reduced risk of mortality or mechanical ventilation in unadjusted (odds ratio, 0.23; 95% confidence interval, 0.08-0.70) and adjusted analyses for clinical characteristics (adjusted OR, 0.20; 95% CI, 0.06-0.67). Conversely, treatment in patients with CRP <10mg/dL was associated with significantly increased risk of mortality or ventilation during analysis.
Bottom line: Glucocorticoids can benefit patients with significantly elevated CRP but may be harmful to those with lower CRPs.
Citation: Keller MJ et al. Effect of systemic glucocorticoids on mortality or mechanical ventilation in patients with COVID-19. J Hosp Med. 2020;8;489-493. Published online first. 2020 Jul 22. doi:10.12788/jhm.3497.
Dr. Halpern is a med-peds hospitalist at Brigham and Women’s Hospital in Boston.