Corticosteroids for COVID-19 patients with different disease severity: a meta-analysis of randomized clinical trials

Pasin, Laura; Navalesi, Paolo; Zangrillo, Alberto; Kuzovlev, Artem; Likhvantsev, Valery; Hajjar, Ludhmila Abrahão; Fresilli, Stefano; Lacerda, Marcus Vinicius Guimaraes; Landoni, Giovanni

OBJECTIVES: : Efficacy and safety of corticosteroids in patients with 2019-nCoV infection are still debated. Since large randomized clinical trials (RCTs) and a well conducted meta-analysis on the use of corticosteroids focused on COVID-19 intensive care unit patients were recently published, we performed a metanalysis of RCTs on corticosteroids therapy in patients with different disease severity to evaluate their effect on survival. DESIGN: : Meta-analyses of RCTs SETTING: : Hospital PARTICIPANTS: : COVID-19 patients INTERVENTIONS: : Corticosteroids MEASUREMENTS AND MAIN RESULTS: : We searched for RCTs performed on adult patients with acute hypoxemic failure related to 2019-nCoV infection, receiving corticosteroids versus any comparator. Primary endpoint was mortality rate. Five RCTs involving 7692 patients were included. Overall mortality of patients treated with corticosteroids was slightly but significantly lower than mortality of controls (26% vs 28%, RR=0.89 [95% CI 0.82 to 0.96], p=0.003). The same beneficial effect was found in the subgroup of patients requiring mechanical ventilation (RR=0.85 [95% CI 0.72-1.00], p=0.05 NNT=19). Remarkably, corticosteroids increased mortality in the subgroup of patients not requiring oxygen (17% vs 13%, RR=1.23 [95% CI 1.00 to 1.62], p=0.05 NNH=29). Tests for comparison between mechanical ventilated and not requiring oxygen subgroups confirmed that treatment with corticosteroids had a statistically significant different effect on survival. Patients treated with corticosteroids had a significantly lower risk of need for mechanical ventilation. CONCLUSIONS: : Corticosteroids may be weighed in severe critically ill COVID-19 patients, but must be discouraged in patients not requiring oxygen therapy. Further trials are urgently warranted before implementing this treatment worldwide.