Real-world evidence of the use of glucocorticoids for severe COVID-19

Abstract

Introduction: Currently, only glucocorticoids have proved to impact adverse outcomes in COVID-19. However, their risk/benefit balance remains inconclusive and populations' characteristics should be considered.

Objective: The objective was to evaluate the real-life use of glucocorticoids in patients with severe COVID-19 hospitalized in a third-level referral center and to determine the type, accumulated doses, and the in-hospital outcomes related with their use.

Methods: We evaluated a retrospective cohort of 737 patients with criteria for severe COVID-19 and a positive polymerase chain reaction (PCR) test for SARS-CoV-2. We extracted data for epidemiological analysis, medical history, and medications, as well as baseline laboratory tests. Data were analyzed using SPSS 21.0 and nonparametric tests, medians, and interquartile ranges (IQR). A p < 0.05 was considered significant.

Results: A total of 65.3% were men, with a median age of 59 years (IQR 46-70) and a median of 10 days of hospital stay (IQR 6-16), more than 40% had diabetes, hypertension, and/or obesity, and 0.8% used steroids chronically. At the time of the study, 54.0% had been discharged due to improvement and 40.8% died. The most common treatment used was dexamethasone 6 mg/day/10 days (46.6%). Patients with a complete dexamethasone scheme [as proposed by the Randomized Evaluation of COVID-19 Therapy (RECOVERY) study] had a lower mortality risk [hazard ratio (HR) 0.441, 95% confidence interval (CI) 0.232-0.840] in comparison with patients with lower doses (HR 1.803, 95% CI 1.080-3.012). Patients with methylprednisolone or several steroids tended to have higher cumulative doses (equivalent to >675 mg of prednisolone).

Conclusion: The use of steroids in severe COVID-19 reduces mortality only at the dose proposed in the RECOVERY study in the younger population. No benefit of the use of steroids was observed in patients with older age or higher number of comorbidities.

Keywords: SARS-CoV-2; dexamethasone; therapeutics.

Figure 1.

Patient selection flowchart. Only patients with positive PCR for SARS-CoV-2 that had not received steroids for COVID-19 as outpatients were included. PCR, polymerase chain reaction.

Figure 2.

Accumulated steroid dose at discharge. All treatments were transformed to the equivalent dose in prednisolone for comparison. An accumulated dose of 675 mg is equivalent to 7.5 mg of prednisolone per day for 90 days. RECOVERY, Randomized Evaluation of COVID-19 Therapy.

Figure 3.

Cox proportional hazard model for mortality depending on steroid doses. A dose lower than that proposed by the RECOVERY trial increased the mortality rate. The analysis was adjusted by those variables that were significant in the bivariate analysis. RECOVERY, Randomized Evaluation of COVID-19 Therapy.