Pulse versus nonpulse steroid regimens in patients with coronavirus disease 2019: A systematic review and meta-analysis

Abstract

Systemic steroids are associated with reduced mortality in hypoxic patients with coronavirus disease 2019 (COVID-19). However, there is no consensus on the doses of steroid therapy in these patients. Several studies showed that pulse dose steroids (PDS) could reduce the progression of COVID-19 pneumonia. However, data regarding the role of PDS in COVID-19 is still unclear. Therefore, we performed this meta-analysis to evaluate the role of PDS in COVID-19 patients compared to nonpulse steroids (NPDS). Comprehensive literature search of PubMed, Embase, Cochrane Library, and Web of Science databases from inception through February 10, 2022 was performed for all published studies comparing PDS to NPDS therapy to manage hypoxic patients with COVID-19. Primary outcome was mortality. Secondary outcomes were the need for endotracheal intubation, hospital length of stay (LOS), and adverse events in the form of superimposed infections. A total of 10 observational studies involving 3065 patients (1289 patients received PDS and 1776 received NPDS) were included. The mortality rate was similar between PDS and NPDS groups (risk ratio [RR]: 1.23, 95% confidence interval [CI]: 0.92-1.65, p = 0.16). There were no differences in the need for endotracheal intubation (RR: 0.71, 95%: CI 0.37-1.137, p = 0.31), LOS (mean difference: 1.93 days; 95% CI: -1.46-5.33; p = 0.26), or adverse events (RR: 0.93, 95% CI: 0.56-1.57, p = 0.80) between the two groups. Compared to NPDS, PDS was associated with similar mortality rates, need for endotracheal intubation, LOS, and adverse events. Given the observational nature of the included studies, randomized controlled trials are warranted to validate our findings.

Keywords: COVID-19; corticosteroids; hospital stay; intubation; mortality; pulse dose steroids.

Figure 1

Preferred reporting items for systematic reviews and meta‐analyses flow diagram for the selection of studies.

Figure 2

Forest plot comparing PDS and NPDS regarding (A) mortality, (B) need for endotracheal intubation, (C) length of hospital stay, and (D) adverse events. NPDS, nonpulse dose steroids; PDS, pulse dose steroids.

Figure 3

(A) Subgroup analysis of studies that included only dexamethasone in the NPDS group for mortality, (B) Subgroup analysis based on the strategy of pulse‐dose steroid therapy (initial vs. rescue therapy) for mortality. NPDS, nonpulse dose steroids; PDS, pulse dose steroids.