Although glucocorticoids were found to decrease mortality in patients with COVID-19 and severe acute respiratory syndrome (SARS), the optimal regimens differed between the 2 diseases, especially in regard to sex- and age-specific effects, doses, and treatment timing, according to a systematic review and meta-analysis published in Shock.
In this meta-analysis, researchers compared the association between all-cause mortality and treatment with glucocorticoids among patients with COVID-19 vs those with SARS. The analysis included 69 studies (N=34,633) on COVID-19 and 12 observational studies (N=11,302) on SARS that occurred between 2002 and October 7, 2020. Of the COVID-19 studies, 59 were observational and 10 were randomized controlled trials (RCT).
Of the COVID-19 studies, results from all RCTs showed a significantly decreased risk of all-cause mortality (risk ratio [RR], 0.88; 95% CI, 0.82-0.94; I2=26%), and results of 52 observational studies showed a significantly increased risk of all-cause mortality (RR, 1.32; 95% CI, 1.08-1.61; I2=99%). Of the SARS studies, results from only those with a decreased risk of bias showed a significantly decreased risk of all-cause mortality (RR, 0.48; 95% CI, 0.29-0.79; I2=10%).
In regard to the COVID-19 studies, further analysis of the RCTs showed that mortality after 28 days or longer was significantly decreased. The researchers noted similar findings among only the observational studies with a decreased risk of bias.
Although treatment with glucocorticoids decreased all-cause mortality in patients with COVID-19 and SARS, especially in those who were severely ill or critical, the beneficial effects differed between the 2 diseases based on various subgroup analyses. In patients with COVID-19, all-cause mortality was significantly decreased among those with severe acute respiratory distress syndrome (ARDS) vs mild ARDS and in patients with increased inflammatory state.
Although all-cause mortality was significantly decreased in men and older patients with COVID-19, no sex- or age-specific effects were noted among patients with SARS. Patients with COVID-19 were likely to benefit from treatment with low- or pulse-dose glucocorticoids, whereas patients with SARS were more likely to benefit from treatment with medium- to high-dose glucocorticoids. Dexamethasone or methylprednisolone appeared to be more effective in patients with COVID-19, and methylprednisolone or prednisolone were more effective in those with SARS. Unlike patients with COVID-19, early treatment with glucocorticoids was associated with an increased clinical benefit in those with SARS.
Future clinical trials and clinical therapy regimens “should seriously consider the sex, age, and timing (severity-of-illness) when administrating glucocorticoids,” concluded the researchers.
Li J, Liao X, Zhou Y, et al. Comparison of associations between glucocorticoids treatment and mortality in COVID-19 patients and SARS patients: a systematic review and meta-analysis. Shock. 2021;56(2):215-228.