Methylprednisolone or dexamethasone, which one is superior corticosteroid in the treatment of hospitalized COVID-19 patients: a triple-blinded randomized controlled trial

Abstract

Background Although almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients. Methods In this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/kg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8). Results There were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040). Conclusion In hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone. Trial registration The trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1).

Effects of early corticosteroid use in patients with severe coronavirus disease 2019

“…Because the rationale for using dexamethasone is clear, many studies using other steroids have not been done. However recent studies have shown that methylprednisolone is not inferior to using dexamethasone [ 20 ].…”

“…The RECOVERY trial is a large-scale, prospective, well-designed study, which demonstrated that the use of dexamethasone reduces mortality in patients with severe COVID-19 [ 11 ]. Other types of corticosteroids, such as hydrocortisone [ 19 ], have also been demonstrated to improve clinical outcomes [ 20 ]. The use of corticosteroids could theoretically cause several side effects [ 21 ], but did not inhibit secondary bacterial infection or viral clearance [ 22 , 23 ].…”

“…Because this trial has strong evidence for corticosteroid use, relatively fewer other studies were conducted. As a result, there is insufficient data to determine which types of corticosteroid (dexamethasone, hydrocortisone, methylprednisolone) are more beneficial [ 20 ], and the appropriate duration [ 24 ] and timing to start corticosteroid use still remain controversial.…”

Systemic Corticosteroid Administration in Coronavirus Disease 2019 Outcomes: An Umbrella Meta-Analysis Incorporating Both Mild and Pulmonary Fibrosis–Manifested Severe Disease

“…The proposed doses for methylprednisolone are 1-2 mg/kg, followed by the same daily dose at an infusion rate of 10 ml/h daily with a gradual taper in this setting (Meduri et al, 2018;Villar et al, 2020). Another study supported that methylprednisolone at 2 mg/kg is superior than dexamethasone at 6 mg/kg with lower MV and reduced hospital stay due to hypothesized higher lung tissue-to-plasma ratios in methylprednisolone (Ranjbar et al, 2021). An individual patient analysis investigating corticosteroid use on early and late ARDS demonstrated improved survival and a decreased duration of MV (Meduri et al, 2016).…”

COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) guidelines; revisiting the Western New York approach as the pandemic evolves

“…Current data supports the use of both IVIG and corticosteroids in all three categories of MIS-C. Dexamethasone has been used as an adjunctive treatment for hospitalized patients with active COVID-19 infection with prominent respiratory features and/or shock; however, methylprednisolone is more commonly used for MIS-C. A recently-published randomized controlled trial and retrospective trials suggest superiority of methylprednisolone over dexamethasone for acute/respiratory COVID-19 [ 51 , 52 ]. We would recommend use of methylprednisolone in all cases of MIS-C, unless there is a high index of suspicion for concomitant infection or if steroids are contraindicated.…”