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Meta-Analysis
. 2021 Mar;159(3):1019-1040.
doi: 10.1016/j.chest.2020.10.054. Epub 2020 Oct 28.

Impact of Corticosteroids in Coronavirus Disease 2019 Outcomes: Systematic Review and Meta-analysis

Edison J Cano  1 , Xavier Fonseca Fuentes  2 , Cristina Corsini Campioli  3 , John C O'Horo  4 , Omar Abu Saleh  3 , Yewande Odeyemi  2 , Hemang Yadav  2 , Zelalem Temesgen  3
Affiliations
Meta-Analysis

Impact of Corticosteroids in Coronavirus Disease 2019 Outcomes: Systematic Review and Meta-analysis

Edison J Cano et al. Chest. 2021 Mar.

Abstract

Background: Since its appearance in late 2019, infections caused by severe acute respiratory syndrome coronavirus 2 have created unprecedented challenges for health systems worldwide. Multiple therapeutic options have been explored, including corticosteroids. Preliminary results of corticosteroids in coronavirus disease 2019 (COVID-19) are encouraging; however, the role of corticosteroids remains controversial.

Research question: What is the impact of corticosteroids in mortality, ICU admission, mechanical ventilation, and viral shedding in COVID-19 patients?

Study design and methods: We conducted a systematic review of literature on corticosteroids and COVID-19 in major databases (PubMed, MEDLINE, and EMBASE) of published literature through July 22, 2020, that report outcomes of interest in COVID-19 patients receiving corticosteroids with a comparative group.

Results: A total of 73 studies with 21,350 COVID-19 patients were identified. Corticosteroid use was reported widely in mechanically ventilated patients (35.3%), ICU patients (51.3%), and severe COVID-19 patients (40%). Corticosteroids showed mortality benefit in severelly ill COVID-19 patients (OR, 0.65; 95% CI, 0.51-0.83; P = .0006); however, no beneficial or harmful effects were noted among high-dose or low-dose corticosteroid regimens. Emerging evidence shows that low-dose corticosteroids do not have a significant impact in the duration of SARS-CoV-2 viral shedding. The analysis was limited by highly heterogeneous literature for high-dose and low-dose corticosteroids regimens.

Interpretation: Our results showed evidence of mortality benefit in severely ill COVID-19 patients treated with corticosteroids. Corticosteroids are used widely in COVID-19 patients worldwide, and a rapidly developing global pandemic warrants further high-quality clinical trials to define the most beneficial timing and dosing for corticosteroids.

Keywords: COVID-19; coronavirus: corticosteroids; outcomes.

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Figures

Figure 1
Figure 1
A, Diagram showing clinical phases of coronavirus disease 2019. B, Diagram showing immunomodulatory effects of glucocorticoid therapy in the nucleus driven by glucocorticoid response elements (GREs) resulting in increased expression of antiinflammatory molecules (annexin-1; nuclear factor of κ light polypeptide gene enhancer in B-cells inhibitor, α [IκBα]; secretory leukocyte protease inhibitor [SLPI], and IL-10) and decreased production of nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB) and proinflammatory cytokines (IL-2, IL-6, and tumor necrosis factor α [TNFα]). CRP = c-reactive protein.
Figure 2
Figure 2
PRISMA flow diagram showing study selection.
Figure 3
Figure 3
Forest plot showing mortality outcomes in coronavirus disease 2019 patients receiving corticosteroids vs those not receiving corticosteroids.
Figure 4
Figure 4
Forest plot showing mortality outcomes in severely ill coronavirus disease 2019 patients receiving corticosteroids vs those not receiving corticosteroids.
Figure 5
Figure 5
Forest plot showing mortality outcomes in coronavirus disease 2019 patients receiving high-dose corticosteroids vs those not receiving corticosteroids.
Figure 6
Figure 6
Forest plot showing mortality outcomes in coronavirus disease 2019 patients receiving low-dose corticosteroids vs those not receiving corticosteroids.
See this image and copyright information in PMC

Comment in

  • Caution When Comparing the Impact of Corticosteroids in COVID-19.
    Confalonieri M, Salton F, Confalonieri P, Rochwerg B, Meduri GU. Confalonieri M, et al. Chest. 2021 Aug;160(2):e243-e244. doi: 10.1016/j.chest.2021.04.026. Chest. 2021. PMID: 34366052 Free PMC article. No abstract available.
  • Response.
    Cano E, Fonseca Fuentes X, Corsini Campioli C, O'Horo JC, Abu Saleh O, Temesgen Z. Cano E, et al. Chest. 2021 Aug;160(2):e244. doi: 10.1016/j.chest.2021.04.028. Chest. 2021. PMID: 34366053 No abstract available.

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