Early corticosteroids are associated with lower mortality in critically ill patients with COVID-19: a cohort study

Pablo Monedero ,Alfredo Gea ,Angel M Candela‐Toha ,María L Hernández-Sanz ,Pedro Castro Rebollo ,Egoitz Arruti ,Jesús Villar ,Carlos Ferrando

doi:10.1186/s13054-020-03422-3

Abstract

BackgroundCritically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose.MethodsThis is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications.ResultsA total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n = 485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens.ConclusionEarly use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.

Highlights

Ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response
The RECOVERY trial has methodological flaws such as the absence of stratification and incomplete information on multiple factors associated with mortality, which may have caused an imbalance between the control and the corticosteroids treated groups [9]
In a large COVID-19 registry of patients admitted into a network of Intensive Care Units (ICU), we examined whether early use of corticosteroids decreases all-cause mortality and improves clinically relevant outcomes

Summary

Introduction

Ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, there are still some concerns regarding its use, timing, and dose. Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first recognized in Wuhan, China, Corticosteroids are used to treat several hyperinflammatory syndromes [3]. The RECOVERY trial [4] and six smaller randomized clinical trials have shown improved outcomes in severe COVID-19 patients treated with corticosteroids [4,5,6]. The WHO meta-analysis [5] has limitations, with 3 incomplete trials stopped prematurely, and excessive weight of the RECOVERY trial, precluding definitive conclusions [9]

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