Authors’ reply
In our meta-analysis,1 the pooled estimate from retrospective studies suggested that the use of glucocorticoids was associated with an increased risk of death. However, this result should be interpreted with caution because the inherent limitations of retrospective studies make it difficult to infer a causal relationship between the use of glucocorticoids and mortality in patients with coronavirus disease 2019 (COVID-19).
Our other study,2 which has been accepted by The Journal of Clinical Investigation recently, also suggested that glucocorticoids use was associated with increased rate of 28-day all-cause mortality and delayed SARS-CoV-2 RNA clearance in patients with severe COVID-19 and acute respiratory distress syndrome. This finding was consistent even after we used propensity score matching analyses, which allowed us to compare the outcomes between the 2 cohorts (the glucocorticoid treatment group vs the nonglucocorticoid treatment group) with similar distributions for baseline variables.
However, the RECOVERY trial3 revealed that the 28-day mortality was significantly lower in the dexamethasone group than in the usual care group. The underlying mechanisms which led to the inconsistent findings between our studies and the RECOVERY trial are largely unknown. But a number of factors (including participants, dosage, and regimen of glucocorticoids, timing of initiation, and duration of administration) which may affect the response to glucocorticoid therapy should be taken into account. For example, in the RECOVERY trial, dexamethasone use did not show benefit (and possibly harmful effects) in patients who did not receive oxygen therapy. In addition, the overwhelming majority of glucocorticoid regimens used in China involved methylprednisolone rather than dexamethasone. Although the RECOVERY trial suggested that glucocorticoids may be a promising drug for patients with COVID-19, further research is still needed to fill current evidence gaps, including answers to the following questions: who will benefit from glucocorticoids therapy, which glucocorticoid regimen and dosage is preferred, when should glucocorticoids therapy be initiated and stopped.
Lei Pei, Sheng Zhang, Xuqiang Geng, Wenfang Li, Dechang Chen (LP and WL: Department of Critical Care Medicine, Changzheng Hospital, Second Military Medical University, Shanghai, China; SZ and DC: Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; XG: Department of Rheumatology and Immunology, Changzheng Hospital, Second Military Medical University, Shanghai, China)
Wenfang Li, MD, Department of Critical Care Medicine, Changzheng Hospital, Second Military Medical University, Shanghai 200 003, China, phone: +86 13501838919, email: chzhedlwf@163.com
None declared.
Pei L, Zhang S, Geng X, et al. Use of corticosteroids in SARS-CoV-2 infection: foe, or can they become a friend? Authors’ reply. Pol Arch Intern Med. 2020; 130: 922-923. doi:10.20452/pamw.15662
- 1.
- Pei L, Zhang S, Huang L, et al. Antiviral agents, glucocorticoids, antibiotics, and intravenous immunoglobulin in 1142 patients with coronavirus disease 2019: a systematic review and meta-analysis. Pol Arch Intern Med. 2020; 130: 726-733.Crossref
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- Liu J, Zhang S, Dong X, et al. Corticosteroid Treatment in severe COVID-19 Patients with Acute Respiratory Distress Syndrome. J Clin Invest. 2020. [In press].
- 3.
- RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med. 2020 Jul 17. [Epub ahead of print].