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Corticosteroids for Coronavirus Tied
to Longer Hospital Stay, Doubled Death Risk
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Mark Mascolini
Meta-analysis of 15 articles involving 5270 adults with coronavirus pneumonia found that a severe lung condition raised chances of corticosteroid use by 56% [1]. The analysis also tied corticosteroids to a doubled risk of death or bacterial infection and to a 6-day longer hospital stay. Notably, statistical analyses did not control for potential confounders.
While clinicians await trial evidence on agents effective against COVID-19, some have turned to corticosteroid therapy to dampen inflammation and rein in immune activation. Although corticosteroids see wide use for symptomatic treatment of severe pneumonia, corticosteroid therapy for coronavirus infection, including SARS, MERS, and COVID-19, remains controversial. For example, suppressing the immune response too much can hamper control of infections such as coronavirus infection.
Newly released COVID-19 guidelines from the Infectious Diseases Society of America (IDSA) advise avoiding corticosteroids in people admitted to the hospital with COVID-19 pneumonia and using corticosteroids "in the context of a clinical trial" for people admitted to the hospital with acute respiratory distress syndrome (ARDS) due to COVID-19 [2].
Researchers in Wuhan, China, the initial epicenter of COVID-19, searched electronic databases from January 1, 2002 to March 15, 2020 for studies of corticosteroids to treat coronavirus infection (SARS, MERS, or COVID-19). Participants had coronavirus pneumonia either treated or not treated with corticosteroids. Researchers excluded anyone already counted in another study and anyone under 18 years old.
The analysis included 5270 individual patients in 15 articles. Because one article did not list the number of people treated with corticosteroids, the study focused on 3176 people treated with corticosteroids and 1780 who received other treatment (4956 total). Eleven articles assessed people with SARS-CoV, 2 studies included patients with MERS-CoV, and 2 focused on people with SARS-CoV-2 infection. Eight articles were written in Chinese and 7 in English.
In 7 studies patients with severe or critical conditions had more than a 50% higher chance of getting corticosteroids than did people with less severe conditions (risk ratio [RR] 1.56, 95% confidence interval [CI] 1.28 to 1.90, P < 0.001). A subanalysis determined that people with severe pneumonia and SARS-CoV-2 infection had more than a 2-fold higher chance of getting corticosteroids (RR 2.36, 95% CI 1.31 to 4.28, P = 0.004).
In the 9 studies that reported mortality, people receiving corticosteroids had more than a doubled risk of dying (RR 2.11, 95% CI 1.13 to 3.94, P = 0.019). Corticosteroid use conferred more than a 6-day longer hospital stay (weighted mean difference 6.31, 95% CI 5.26 to 7.37, P < 0.001).
People treated with corticosteroids ran a twice higher risk of bacterial infection (RR 2.08, 95% CI 1.54 to 2.81, P < 0.001) and hypokalemia (low potassium) (RR 2.21, 95% CI 1.07 to 4.55, P = 0.032). But corticosteroid use had no impact on risk of hyperglycemia (high blood sugar) or hypocalcemia (low calcium).
The new IDSA guidelines found no studies that specifically assessed corticosteroid therapy for acute COVID-19 [2]. The IDSA pointed to an earlier systemic review of 15 studies for SARS and MERS [3]. Thirteen of these studies reached no conclusion on the impact of corticosteroids for these coronavirus diseases. One randomized controlled trial in this analysis found delayed viral clearance associated with corticosteroid use.
References
1. Yang Z, Liu J, Zhou Y, Zhao X, Zhao Q, Liu J. The effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis. J Infect. 2020. doi: https://doi.org/10.1016/j.jinf.2020.03.062
2. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. April 11, 2020.
https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
3. Stockman LJ, Bellamy R, Garner P. SARS: systematic review of treatment effects. PLoS Med. 2006;3(9):e343.
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