Low-dose Corticosteroids Research Articles

Anakinra or high-dose corticosteroids in COVID-19 pneumonia patients who deteriorate on low-dose dexamethasone: an observational study of comparative effectiveness

ObjectivesTo assess whether escalating to high-dose corticosteroids or anakinra compared with continuing low-dose corticosteroids reduced mortality in patients with severe COVID-19 whose respiratory function deteriorated while receiving dexamethasone 6 mg daily. MethodsWe conducted a retrospective cohort study between March 1 to December 31, 2020, of hospitalized patients with confirmed COVID-19 pneumonia. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving anakinra, high-dose corticosteroid (dexamethasone >10 mg daily), or remaining on low-dose corticosteroids on the day of first respiratory deterioration. ResultsWe analyzed 6671 patients whose respiratory status deteriorated while receiving dexamethasone 6 mg daily for COVID-19 pneumonia, of whom 6265 stayed on low-dose corticosteroids, 232 were escalated to high-dose corticosteroids, and 174 to anakinra in addition to corticosteroids. The propensity score-adjusted odds of death were higher in the anakinra (odds ratio [OR] 1.76; 95% CI 1.13-2.72) and high-dose corticosteroid groups (OR 1.53; 95% CI 1.14-2.07) compared with those who continued low-dose corticosteroids on the day of respiratory deterioration. The odds of hospital-acquired infections were also higher in the anakinra (OR 2.00; 95% CI 1.28-3.11) and high-dose corticosteroid groups (OR 1.43; 95% CI 1.00-2.04) compared with low-dose corticosteroid group. ConclusionOur findings do not support escalating patients with COVID-19 pneumonia who deteriorate on low-dose corticosteroids to high-dose corticosteroids or anakinra.

Effect of Sequential Intravenous Pulse Cyclophosphamide-Azathioprine in Systemic Sclerosis-Interstitial Lung Disease: An Open-Label Study

Systemic sclerosis (SSc) is a rare connective tissue disorder of unknown aetiology. Pulmonary involvement contributes substantially to its morbidity and mortality. Treatment of pulmonary disease due to SSc remains unsatisfactory. We examined the effect of sequential six-month intravenous pulse therapy with cyclophosphamide (CYC) followed by azathioprine and low-dose corticosteroids on SSc associated interstitial lung disease (SSc-ILD). In a single-centre, prospective, observational, open-labelled study; nine patients (eight females, one male) with SSc-ILD were treated with intravenous pulse CYC (600mg/m(2) body surface area) at monthly interval for six cycles with oral prednisolone 10mg daily. Subsequently, azathioprine (2-3mg/Kg) was administered while continuing with the same dose of prednisolone. Primary end-points were forced vital capacity (FVC) and high resolution computed tomography (HRCT) scan of thorax score. Secondary end-points were quality of life measured by health assessment questionnaire-disability index (HAQ-DI) and six-minute walk distance (6WMD) test. After one year of observation, the FVC showed significant improvement (p=0.003). The 6WMD also improved significantly (p=0.0028). However, change in HRCT scan scoring and HAQ-DI score was not significant. Intravenous, pulse CYC followed by azathioprine along with low-dose corticosteroids produces significant improvement in FVC and 6WMD at 12-month follow-up without significant change in radiological manifestations and health status.

Corticosteroid administration and glycemic outcomes during treatment of acute exacerbation of chronic obstructive pulmonary disease

BackgroundWhile international guidelines recommend low doses of systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) clinical practice patterns show significant heterogeneity. Increasing doses of corticosteroids have inconsistently been associated with a greater risk of hyperglycemia. MethodsPatients admitted to inpatient services for AECOPD were retrospectively enrolled. Hospitalization corticosteroid doses, daily blood glucose levels, and other markers of corticosteroid excess were collected. Correlative and regression analyses were conducted to assess the relationship between corticosteroid dose and average hospitalization blood glucose. ResultsDaily corticosteroid dose significantly predicted a higher blood glucose (rs=0.179, p=0.0095; p<0.0028 respectively) and cumulative corticosteroid dose predicted a longer hospital length of stay in bivariate and multivariate analyses (rs=0.679, p<0.0001; p<0.0001 respectively). Patients that experienced hypernatremia, hypokalemia, acute hyperglycemia, and acute hypertension received larger corticosteroid doses than patients that did not experience these complicating events. ConclusionsWe identified that increasing amounts of corticosteroids administered to inpatients experiencing AECOPD experienced higher average hospitalization blood glucose values, protracted hospitalizations, and other untoward effects.

La cytosteatonecrose du nouveau-ne au chu de Conakry: a propos d’une nouvelle observation

Cytosteatonecrosis is an acute condition of unknown pathogenesis that occurs in the first weeks of extra-uterine life. It presents clinically in the form of a large plaque, indurated and sometimes nodular. It often sits on the trunk, buttocks and thighs (root of the limbs). The course of cytosteatonecrosis is benign but sometimes enamelled with complications such as hypercalcemia and metabolic disorders. The rarity of this affection would be justified by the ignorance of the cutaneous signs. We report here a case of neonatal cytosteatonecrosis remarkable for the delay in diagnosis and the efficacy of low-dose corticosteroid therapy.

EVALUATION AND MANAGEMENT OF DELAYED HYPERSENSITIVITY REACTION TO INSULIN IN

<h3>Introduction</h3> Type I hypersensitivity to insulin is rare. In most adverse reactions to insulin, additives, excipients, or preservatives are implicated, resulting in type III or IV hypersensitivity. We describe an adolescent patient with delayed type hypersensitivity to insulin and discuss evaluation and management strategies. <h3>Case Description</h3> A 16-year-old female with type I diabetes mellitus used an insulin pump without problems for 6 years. Recently, she began to develop a delayed, itchy, painful pump site rash. Symptoms were managed with pump site rotation, trials of various insulins, trials of return to manual insulin injections, and oral antihistamines. A variety of allergy testing—percutaneous, intradermal, and patch—has been largely negative, suggesting against type I and IV hypersensitivities. Punch biopsy of the rash was performed with basic pathology and various stains completed, consistent with type IV hypersensitivity. Table 1 shows test results. <h3>Discussion</h3> Type III hypersensitivity was the leading differential diagnosis given some delayed intradermal positive results, negative patch testing, and previous positive serum IgG to insulin; however, biopsied tissue did not show immune complex deposition. The pathology was more consistent with a type IV hypersensitivity. Little is known about effectively managing these delayed hypersensitivity reactions as insulin therapy continues. Our patient started adjunctive metformin therapy and will undergo additional, extensive patch testing with Dermatology. Other therapies to consider include low-dose corticosteroid co-infusion with insulin and/or biologic drug therapy. It is important to distinguish that these patients do not have insulin allergy but may require support from an allergist to facilitate comfortable receipt of chronic diabetes treatment.

High-dose corticosteroids in patients hospitalized for COVID-19 pneumonia: an observational study of comparative effectiveness

ObjectivesTo assess whether high- compared with low-dose corticosteroids started upon hospitalization reduce mortality in patients with severe COVID-19 pneumonia or in subgroups stratified by severity of respiratory impairment on admission. MethodsWe conducted a retrospective cohort study of patients with confirmed SARS-CoV-2 infection who required oxygen supplementation upon hospitalization between March 1 and December 31, 2020. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving low- or high-dose corticosteroid (dexamethasone 6-10 mg daily or >10-20 mg daily or other corticosteroid equivalents). ResultsWe analyzed 13,366 patients who received low-dose and 948 who received high-dose corticosteroids, of whom 31.3% and 40.4% had severe respiratory impairment (>15 l/min of oxygen or mechanical ventilation) upon admission, respectively. There were no differences in the propensity score-adjusted odds of death (odds ratio 1.17, 95% CI 0.72-1.90) or infections (odds ratio 0.70, 95% CI 0.44-1.11) for patients who received high-dose compared with low-dose corticosteroids, beginning on the day of admission. No significant differences in subgroups stratified by severity of respiratory impairment were found. ConclusionInitiating high-dose compared with low-dose corticosteroids among newly hospitalized patients with COVID-19 pneumonia did not improve survival. However, benefit of high-dose corticosteroids in specific subgroups cannot be excluded.

A pragmatic randomized controlled trial of standard care versus steroids plus standard care for treatment of pneumonia in adults admitted to Kenyan hospitals (SONIA)

Background: It is unclear if adjunctive steroid therapy reduces mortality in community-acquired pneumonia, as very few studies have had mortality as a primary outcome. This question has become even more relevant following demonstration of a mortality benefit of dexamethasone when used in patients with COVID-19 who had severe disease. This has led to increased prescription of steroids in adults with community acquired pneumonia in low-resource settings even when their COVID-19 diagnosis is uncertain due to low testing rates. This pragmatic parallel randomised-controlled open-label trial will determine if adjunctive low-dose steroids for treatment of adults admitted to hospital with community acquired pneumonia whose SARS-CoV-2 status is either unknown or negative reduces mortality. Methods: We will enroll and randomize 2180 patients admitted with a clinical diagnosis of community acquired pneumonia into two arms; in Stratum A-participants will receive standard care for the treatment of community acquired pneumonia. In Stratum B-participants will receive a 10-day course of low-dose oral corticosteroids in addition to standard care. All participants will be followed up to 30 days post randomization and their final status recorded (alive or dead). An immunology sub study will be conducted on a subset of the trial participants (50 per arm) to determine the correlation of pre-existing and treatment induced immune and metabolic changes with study outcomes. Discussion: Mortality among adults admitted to hospital with community acquired pneumonia in resource-limited settings is high. Steroids are readily available in these settings. If the addition of steroids to standard care for community acquired pneumonia is found to be beneficial, this easily scalable intervention would significantly reduce the currently high mortality associated with the illness.

Effect of corticosteroids in patients with COVID-19: a Bayesian network meta-analysis

ObjectivesWe sought to perform a network meta-analysis to compare the safety and efficacy of the systemic administration of corticosteroids for the treatment of COVID-19. MethodsA Bayesian network meta-analysis was performed to combine the direct and indirect evidence. The surface under the cumulative ranking curve was obtained to estimate the ranking probability of the treatment agents for each outcome. The efficacy outcome was 28-day all-cause mortality. The safety outcome was serious adverse events. ResultsA total of 16 trials with 2992 patients comparing four treatments (dexamethasone, hydrocortisone, methylprednisolone, and placebo) were identified. Direct analysis showed that corticosteroids were associated with a reduced risk of 28-day mortality compared with usual care (risk ratio [RR] 0.83; 95% confidence interval [CrI] 0.70-0.99). Network analysis showed that the pooled RR was 0.63 (95% CrI 0.39-0.93) for all-cause mortality at 28 days comparing methylprednisolone with usual care or placebo (surface under the cumulative ranking curve: 91%). Our analysis demonstrated that patients who received a low dose of corticosteroids (RR 0.80; 95% CrI 0.70-0.91) and a long course of treatment (RR 0.81; 95% CrI 0.71-0.91) had higher survival rates than patients in the placebo group. ConclusionAdministration of corticosteroids was associated with a reduced all-cause mortality at 28 days compared with placebo or usual care. Our analysis also confirmed the mortality benefit associated with low-dose and long-term treatment with corticosteroids.

CARDIOGENIC SHOCK AND CRITICAL ILLNESS-RELATED CORTICOSTEROID INSUFFICIENCY: DID STEROIDS MAKE MY HEART GO ON?

CARDIOGENIC SHOCK AND CRITICAL ILLNESS-RELATED CORTICOSTEROID INSUFFICIENCY: DID STEROIDS MAKE MY HEART GO ON?

Corticosteroid effectiveness among hospitalised COVID-19 patients in Malaysia.

Using steroids to manage hospitalised coronavirus disease 2019 (COVID-19) patients caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has been shown to reduce the need for mechanical ventilation and mortality. To date, low-dose dexamethasone and methylprednisolone corticosteroids have been effective in reducing the infection's progress in hospitalised patients. However, it is unknown if high dosages of corticosteroids can achieve a better clinical outcome. This study aims to compare the clinical outcomes of hospitalised COVID-19 patients who are given a 10-day low-dose corticosteroid treatment (IV 2 mg/kg/day methylprednisolone loading dose (LD) then 0.25 mg/kg four times a day (q.i.d.)) with patients given a 10-day high-dose corticosteroid treatment (IV 20 mg dexamethasone once daily (o.d.) or a 1.5 mg/kg prednisolone tablet o.d.). Retrospective data on hospitalised COVID-19 patients were collected for this study, and the primary outcome measure was the patients' clinical status based on the World Health Organization's (WHO) Ordinal Scale for Clinical Improvement (OSCI) on Day-5 and Day-10 post-steroid. The results demonstrated that using steroids significantly improved patients' clinical outcomes from a WHO OSCI level of 4 (0.1) on Day-1 to 2.6 (2.5) on Day-5 (p < 0.001). There was no significant difference in clinical outcome between low-dose and high-dose corticosteroid treatment on Day-5 (H = 2.15; p = 0.34) and Day-10 (H = 1.12; p = 0.58). This study concludes that using low-dose corticosteroids is recommended for hospitalised COVID-19 patients to ensure clinical outcomes are optimised.

Post-COVID corticosteroid use and pulmonary fibrosis: 1 year follow-up

Purpose: Depending on the prevalence and severity of COVID-19 disease, pulmonary sequelae and fibrotic lung disease continue to pose significant problems for patients in the post-COVID period. In our study, we aimed to determine the risk factors for pulmonary sequelae and fibrosis with post-COVID patient management.&#x0D; Materials and Methods: The study comprised 67 post-COVID patients who were released from the hospital after receiving low-dose corticosteroids (0.5 mg/kg daily methylprednisolone) as a result of COVID-19. Socio-demographic data, radiological and laboratory findings of the patients were recorded. All patients were followed up at 3, 6, and 12 months after discharge, and the diagnosis of pulmonary fibrosis was made according to high resolution computed tomography (HRCT) findings, by evaluating with detailed biochemical blood tests and HRCT.&#x0D; Results: Thirtyfour (50.7%) of the 67 patients were male and the mean age was 57±16.33 (min.19–max.90). At 3 months, there were 59 patients (88.1%) with aberrant thoracic computed tomography (CT) findings, 28 (41.8%) at 6 months, and 21 (31.3%) at 12 months. In the 12th month follow-up, pulmonary fibrosis was detected in a total of 9 (13.4%) patients according to thorax CT findings. &#x0D; Conclusion: In our study, the most important risk factors for the development of post-COVID pulmonary fibrosis were intensive care unit (ICU) follow-up, lymphocyte count

Transient spontaneous osteonecrosis of the knee (SONK) shortly after SARS-CoV-2 infection: A report of 2 cases

This article describes 2 cases of post-coronavirus disease 2019 (COVID-19) transient spontaneous osteonecrosis of the knee (PCT-SONK) observed in patients who had previously recovered from COVID-19 without corticosteroid administration. The possible pathomechanisms by which a recent SARS-CoV-2 infection may contribute as a causative factor for osteonecrosis are reviewed, and the differential diagnosis and treatment are discussed. Two patients (males, 45- and 47-year-old) presented with sudden onset knee pain with no trauma history. The pain persisted during rest and at night. On magnetic resonance imaging (MRI), no subchondral bone thickening was observed; bone edema was diffusely distributed in the whole femoral condyle, in contrast to the more focal edema that is typically concentrated mainly around the subchondral region in classic SONK. Both patients were treated nonoperatively with no weight bearing and pharmacological agents, and complete resolution of symptoms was achieved. A follow-up MRI 10 weeks after presentation revealed a near-complete loss of signal in the medial femoral condyle in both patients. Orthopedic surgeons should be cautious when sudden knee pain without concurrent trauma or a history of injury occurs shortly after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, even with mild COVID-19 illness. While some studies report the development of post-COVID-19 osteonecrosis after lower doses of corticosteroids and sooner after their administration than in comparable non-COVID-19 cases, our study is the first to report 2 cases with no corticosteroid administration at all. Therefore, the authors believe it adds to the body of knowledge on the potential connections between COVID-19 and PCT-SONK. The transient nature of symptoms and radiological findings suggest that aggressive surgical treatment of non-injury local bone edema occurring shortly after SARS-CoV-2 infection should be avoided.

Effects of Belimumab (BEL) on Renal Outcomes in Patients (pts) With Relapsed and Newly Diagnosed Active Lupus Nephritis (LN)

Despite standard therapy (ST) for LN, only 20–40% of pts achieve complete renal response (CRR) at 0.5–1 year and 20–25% relapse in 3–5 years. The aim of this study was to assess effects of BEL on renal outcomes in relapsed and newly diagnosed pts with LN. Post hoc analysis of the Phase 3, randomized, double-blind, 104-week BLISS-LN study (GSK BEL114054; NCT01639339). Pts with active LN received monthly intravenous (IV) BEL 10 mg/kg or placebo (PBO) + ST. Randomization was stratified by induction regimen: high dose corticosteroids (HDCS) + cyclophosphamide (CYC), followed by azathioprine + low-dose corticosteroids (LDCS), or HDCS + mycophenolate mofetil (MMF), followed by MMF + LDCS. We assessed primary efficacy renal response (PERR; uPCR ≤0.7; eGFR no more than 20% below pre-flare value or ≥60 ml/min/1.73m2; no rescue therapy) and CRR (uPCR <0.5; eGFR no more than 10% below pre-flare value or ≥90 ml/min/1.73m2; no rescue therapy) at Week 104 and time to renal-related event or death in relapsed vs newly diagnosed pts. Of 446 pts included in this analysis, 150 had relapse of LN and 296 were newly diagnosed. Positive effects of BEL vs PBO on PERR and CRR were noted in both subgroups and were numerically greater in relapsed vs newly diagnosed pts (Table). BEL-treated pts had a lower risk at any time of experiencing a renal-related event or death vs PBO in both subgroups ( Table 1 ). These data suggest BEL improved PERR and CRR rates more potently in relapsed pts, in which PERR and CRR were substantially less frequent compared with newly diagnosed LN.

Présentation « Castleman-like » de lupus systémique : à propos d’un cas

IntroductionCastleman disease is a rare lymphoproliferation, which may mimic systemic lupus. Conversely, systemic lupus sometimes presents like an hematological malignancy. In these cases, a “Castleman-like” histology has been exceptionally described. ObservationA 55-year-old female treated by methotrexate for systemic lupus with skin and joint involvement presented weight loss, polyadenopathy and clinical signs of lupus flare. Biology showed pancytopenia, complement activation, and positive anti-DNA antibodies. PET/CT showed hypermetabolic polyadenopathy. The lymph node biopsy showed “Castleman-like” features. Treatment with corticosteroids and azathioprine resulted in complete remission. ConclusionSystemic lupus and Castleman disease may share common clinical, biological, and histological features. The presence of specific elements of systemic lupus flare and the remission obtained by low-dose corticosteroids results in considering the diagnosis of Castleman-like systemic lupus and avoiding treatment intensification.

Tocilizumab induced immunosuppression in a case of adult-onset still’s disease: are these newer biologics double edged sword?

Adult-onset still’s disease (AOSD) is a rare multisystemic inflammatory disorder of unknown etiology characterised by high spiking fever, evanescent skin rash, arthralgias, arthritis, neutrophilic leucocytosis. Initial treatment strategy includes use of hands-on drugs like non-steroidal anti-inflammatory drugs, low dose corticosteroids, conventional DMARDs. But as the disease progresses to severe form, targeted and biologic DMARDs could be the option for management. Interleukin-6 being one among the many cytokines involved in the pathogenesis of AOSD, has made itself a target for the treatment of refractory cases. Tocilizumab, a recombinant humanized anti IL-6 monoclonal antibody, is one such biologic drug available in the market that has proven its therapeutic efficacy in several clinical trials. We are presenting a case of 37-year-old female patient, known case of AOSD for 4 years. Patient was initially maintained on low dose corticosteroid and conventional DMARD like hydroxychloroquine and methotrexate. Flare ups of the disease warranted the use of tocilizumab and tofacitinib in this patient. After clinical as well as pathological improvement with tocilizumab 2 years before, signs of immunosuppression were observed when tocilizumab was reintroduced for the treatment. Patient suffered from acute pyelonephritis, septicemia, shock, oropharyngeal candidiasis and bronchitis which could be owned to immunosuppressive action of tocilizumab. One can reduce the chances of infection and other adverse effects by careful periodic monitoring of various laboratory parameters like total W.B.C., total platelet count and liver enzymes. Cautious selection of the patient is needed for the treatment with newer biologic agents.

Methotrexate and low-dose corticosteroid: An effective alternate against corticosteroid-resistant granulomatous lobular mastitis.

Granulomatous lobular mastitis (GM) is an inflammatory breast disease with unknown etiology. Studies showed that some patients could achieve complete remission with corticosteroids and excisional surgery. However, some patients would suffer from corticosteroid resistance. We aim to report our single-center experience with the highest number of corticosteroid-resistant GM patients treated by methotrexate and low-dose corticosteroid. The medical record database in our center was searched retrospectively for GM patients between January 2015 and January 2022. Patients suffered corticosteroid resistance and received methotrexate-containing regimen were included in this study. The clinical characteristics, management and outcomes were collected and analyzed. Eighty-one patients with the median follow-up of 18 months (range 5-61 months) were included. The median age was 30 years old (range 21-48 years). The common initial complaints were breast mass, pain, and erythema. The initial treatment of 80 (98.8%) patients was methylprednisolone. Patients were switched to methotrexate and low-dose corticosteroid due to corticosteroid resistance. Complete remission was achieved in 61 (75.3%) patients who received methotrexate and low-dose corticosteroid with or without segmental dissection. Nineteen methotrexate-resistant patients were referred for antimycobacterial treatment with the exception that one patient was lost during follow-up. Thirteen of them achieved complete remission, and the other five gained partial remission and received segmental dissection. None of these methotrexate-resistant patients recured. An approach with methotrexate and low-dose corticosteroid should be considered as an alternative method to corticosteroid-resistant GM patients.

The Treatment of Myelin Oligodendrocyte Glycoprotein Antibody Disease: A State-of-the-Art Review.

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) is an important etiology of neurologic morbidity and specifically, atypical, and relapsing optic neuritis. This review summarizes acute treatment and long-term prevention approaches in MOGAD. PubMed and Google Scholar databases were manually searched and reviewed. We review the evidence base for acute treatment of MOGAD with corticosteroids and adjunct therapies, such as intravenous immunoglobulin (IVIg) and plasma exchange. We discuss the utility of prolonged corticosteroid tapering after the acute attack. We then summarize the commonly used disease-modifying treatments for relapsing MOGAD, including chronic low-dose corticosteroids, classic antirheumatic immune suppressants, biologic agents, and IVIg. While acute MOGAD attacks are usually treated with high-dose IV corticosteroids, longer oral corticosteroid tapers may prevent rapid relapse. Multiple long-term treatment strategies are being employed in recurrent MOGAD, with IVIg is emerging as probably the most effective therapy.

Clinical, imaging features and treatment response of idiopathic hypertrophic pachymeningitis

BackgroundIdiopathic hypertrophic pachymeningitis (IHP) is a rare inflammatory disease that causes focal or diffuse thickening of the dura mater. However, longitudinal follow up studies are still lacking for these patients. ObjectiveTo investigate the clinical characteristics, neuroimaging findings, treatment response and outcome of IHP. MethodA retrospective case series of 30 patients admitted Beijing Tiantan Hospital were screened via Hospital Information System from January 1st, 2011, to January 31st, 2021. All patients' clinical symptoms, imaging, and treatment response were collected via a standardized form. We compared the effects of high-dose and low-dose corticosteroids on headache, impaired vision, and MRI remission during acute onset. The effects of different immunosuppressants on preventing relapses were also compared. ResultsHeadache (93.3%) and multiple cranial neuropathy (66.7%) were the most common symptoms of IHP. Cerebral spinal fluid test showed that protein levels were elevated in 17 (56.7%) patients, and white blood cells were increased in seven patients. MRI demonstrated that diffuse (60%) and focal (40%) enhancement occurred in the dura mater, especially in the tentorium cerebellum (80%). High-dose and low-dose corticosteroids reduced headache and dural enhancement during the acute phase. The high dose corticosteroid significantly relieved the headache than the low dose group (p = 0.041). Patients treated with mycophenolate mofetil and cyclophosphamide might achieve longer remission (months, p = 0.428). ConclusionHeadache and multiple cranial neuropathy are the most common clinical manifestations of IHP. In this study, almost all patients had a good initial response to corticosteroid therapy during the acute phase. Mycophenolate mofetil and cyclosporine may be effective for preventing relapses.

Efficacy of low-dose corticosteroids in patients with acute respiratory distress syndrome: a prospective observational study.

BackgroundThere is still no agreement on whether corticosteroids can reduce mortality in patients with acute respiratory distress syndrome (ARDS). The aim of this study was to investigate the efficacy of low-dose corticosteroid administration in patients with ARDS.MethodsA prospective observational study of patients with ARDS in 17 hospitals in China was performed between March 2016 and February 2018. Propensity score matching was performed to adjust for differences in baseline characteristics between different groups. The effects of corticosteroids were assessed by using the Kaplan-Meier method and a multivariate Cox regression.ResultsA total of 527 ARDS patients were enrolled in the study. Sixty-five patients (12.3%) were administered low-dose (methylprednisolone ≤1 mg·kg−1·d−1) corticosteroids. The median dose was equivalent to 0.67 (0.57–0.81) mg/kg methylprednisolone for a median duration of 10 days. The control group included 224 patients (42.5%) who had never receive corticosteroids. In the matched sample, the hospital mortality rates in the low-dose (n=40) and control groups (n=80) were 27.5% and 42.5% (P=0.110), respectively. The length of hospital stay was significantly longer in the low-dose corticosteroid group than in the control group (24.0 vs. 17.0, P=0.002), and the multivariate Cox regression analysis suggested that the low-dose group had a significantly lower risk of death than the control group (HR: 0.48; 95% CI: 0.24–0.97; P=0.040).ConclusionsThe administration of low-dose corticosteroids may reduce mortality in patients with ARDS.

Impact of dexamethasone on the incidence of ventilator-associated pneumonia in mechanically ventilated COVID-19 patients: a propensity-matched cohort study

ObjectiveTo assess the impact of treatment with steroids on the incidence and outcome of ventilator-associated pneumonia (VAP) in mechanically ventilated COVID-19 patients.DesignPropensity-matched retrospective cohort study from February 24 to December 31, 2020, in 4 dedicated COVID-19 Intensive Care Units (ICU) in Lombardy (Italy).PatientsAdult consecutive mechanically ventilated COVID-19 patients were subdivided into two groups: (1) treated with low-dose corticosteroids (dexamethasone 6 mg/day intravenous for 10 days) (DEXA+); (2) not treated with corticosteroids (DEXA−). A propensity score matching procedure (1:1 ratio) identified patients' cohorts based on: age, weight, PEEP Level, PaO2/FiO2 ratio, non-respiratory Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index (CCI), C reactive protein plasma concentration at admission, sex and admission hospital (exact matching).InterventionDexamethasone 6 mg/day intravenous for 10 days from hospital admission.Measurements and main resultsSeven hundred and thirty-nine patients were included, and the propensity-score matching identified two groups of 158 subjects each. Eighty-nine (56%) DEXA+ versus 55 (34%) DEXA− patients developed a VAP (RR 1.61 (1.26–2.098), p = 0.0001), after similar time from hospitalization, ICU admission and intubation. DEXA+ patients had higher crude VAP incidence rate (49.58 (49.26–49.91) vs. 31.65 (31.38–31.91)VAP*1000/pd), (IRR 1.57 (1.55–1.58), p < 0.0001) and risk for VAP (HR 1.81 (1.31–2.50), p = 0.0003), with longer ICU LOS and invasive mechanical ventilation but similar mortality (RR 1.17 (0.85–1.63), p = 0.3332). VAPs were similarly due to G+ bacteria (mostly Staphylococcus aureus) and G− bacteria (mostly Enterobacterales). Forty-one (28%) VAPs were due to multi-drug resistant bacteria. VAP was associated with almost doubled ICU and hospital LOS and invasive mechanical ventilation, and increased mortality (RR 1.64 [1.02–2.65], p = 0.040) with no differences among patients' groups.ConclusionsCritically ill COVID-19 patients are at high risk for VAP, frequently caused by multidrug-resistant bacteria, and the risk is increased by corticosteroid treatment.Trial registration: NCT04388670, retrospectively registered May 14, 2020.