A Retrospective Controlled Cohort Study of the Impact of Glucocorticoid Treatment in SARS-CoV-2 Infection Mortality

Abstract

Background: Evidence to support the use of steroids in COVID-19 pneumonia is lacking. We aim to determine the impact of steroid use in COVID-19 pneumonia in-hospital mortality. Patients and Methods: We performed a single-center retrospective cohort study in a University hospital in Madrid, Spain, during March 2020. To determine the role of steroids in in-hospital mortality, patients admitted with SARS-CoV-2 pneumonia and treated with steroids were compared to patients not treated with steroids, adjusting by a propensity-score for steroid treatment. Survival times were compared using log-rank test. Different steroid regimens were compared, and adjusted with a second propensity score. Results: During the study period, 463 out of 848 hospitalized patients with COVID19 pneumonia fulfilled inclusion criteria. Among them, 396 (46.7%) patients were treated with steroids and 67 patients were not. Global mortality was 15.1%. Median time to steroid treatment from symptom onset was 10 days (IQR 8-13). In-hospital mortality was lower in patients treated with steroids than in controls (13.9% [55/396] versus 23.9% [16/67], HR 0.51 [0.27-0.96], p= 0.044). Steroid treatment reduced mortality by 41.8% relative to no steroid treatment (RRR 0,42 [0.048- 0.65). Initial treatment with 1 mg/kg/day of methylprednisolone versus steroid pulses was not associated with in-hospital mortality (13.5% [42/310] versus 15.1% [13/86], OR 0.880 [0.449-1.726], p=0.710). Conclusions: Our results show that survival of patients with SARS-CoV2 pneumonia is higher in patients treated with glucocorticoids than in those not treated. In-hospital mortality was not different between initial regimens of 1 mg/kg/day of methylprednisolone and glucocorticoid pulses.

Corticosteroid use in COVID-19 patients: A systematic review and meta-analysis on clinical outcomes

“…[33] Fernandez-Cruz et al reported lower mortality in patients with COVID-19 pneumonia complicated with ARDS and/or a hyperin ammatory syndrome treated with corticosteroids (HR 0.36, 95% CI 0.14 to 0.93, p=0.04). [46] In the other four studies, no signi cant difference in mortality rates between steroid and non-steroid groups, [36,40,48] or even an increased risk in the group that received corticosteroids was demonstrated. [50] However, Lu et al did note that every increase of 10 mg in hydrocortisone equivalent dosage was associated with a 4% elevation of the mortality risk (HR 1.04, 95% CI 1.01-1.07).…”

“…[42,43] In the remaining eight studies, the risk of corticosteroid use was quanti ed, and these were included to calculate the pooled estimate. [23,33,36,37,40,46,48,50] The overall pooled estimate (observational studies and the RCT) showed a favorable outcome in the corticosteroid group (relative risks RR 0.55, 95% CI 0.27-0.83, random effects) ( Figure 2).…”

“…[33,[38][39][40][41][42][43] The median time of initiation after admission was reported in 8/22 studies and varied from 24 hours after hospital admission, [44] immediately after ICU admission [43] to approximately eight to fourteen days after onset of symptoms. [23,41,42,[45][46][47] One study compared early (average 2 days after hospital admission) to late corticosteroid administration (average 5 days after hospital admission). [33] Methylprednisolone was the most frequently used corticosteroid (13/22 studies).…”

“…[33] Methylprednisolone was the most frequently used corticosteroid (13/22 studies). [33,[37][38][39][40][42][43][44]46,[48][49][50][51] In two studies methylprednisolone, hydrocortisone, or dexamethasone was used. [36,41] Ling et al used prednisolone or dexamethasone, [52] and Horby et al reported on dexamethasone use.…”

“…In four of these eight studies, a bene cial effect on mortality was demonstrated. [23,33,37,46] Horby et al demonstrated in a RCT of 6,425 patients that dexamethasone reduced mortality among patients receiving oxygen or invasive mechanical ventilation at allocation of treatment: dexamethasone reduced mortality by one-third in patients who received invasive mechanical ventilation (RR 0.64, 95% CI 0.51 to 0.81) and by one-fth in patients receiving oxygen (RR 0.82, 95% CI 0.72 to 0.94). No positive effect was found in patients who did not receive respiratory support.…”