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September 02, 2020

Steroids reduce death rate of critically ill COVID-19 patients, WHO analysis says

'These results are clear and instantly usable in clinical practice,' epidemiologist says

The World Health Organization has updated its COVID-19 treatment guidelines in response to research that shows steroids significantly reduce the mortality rate of patients in intensive care. 

The WHO now recommends critically ill patients be treated with a corticosteroid for 7 to 10 days. 

The updated guidelines are based on an analysis of seven clinical trials involving three types of corticosteroids. The findings were published Wednesday in the Journal of the American Medical Association.

Steroids often are prescribed to reduce inflammation in conditions like rheumatoid arthritis and eczema. In COVID-19 patients, unchecked inflammation often leads to acute respiratory distress syndrome. The drugs reduce the hyperactivity of the immune system, keeping it from attacking the lungs. 

The WHO analysis included pooled data from trials involving hydrocortisone, dexamethasone and methylprednisolone. In total, 678 patients were randomized to receive steroid treatment and 1,025 patients received a placebo or standard care. Twenty-nine percent of the patients were women.

The steroids were administered in low doses and found to be more effective in reducing mortality than standard care alone. The researchers reported that 33% of the patients treated with steroids died compared to 41% in the placebo or standard care group. This translates to a 34% reduction in the risk of death.

Age, sex or length of illness did not appear to influence the results. Even patients on ventilators improved with steroid treatment. No significant serious adverse events were reported. 

"These results are clear, and instantly usable in clinical practice," Martin Landray, a professor of medicine and epidemiology at the University of Oxford said in a press briefing. "Among critically ill patients with COVID-19, low-dose corticosteroids ... significantly reduce the risk of death."

Landray was involved a dexamethasone trial that first found steroids could be used to save the lives of the most critically ill COVID-19 patients. The RECOVERY trial found that dexamethasone reduced mortality by 35% in ventilated patients and by 20% in patients who needed oxygen but who weren't ventilated.

Nahid Bhadelia, medical director of the Special Pathogens Unit at the Boston University School of Medicine, told STAT News that since June "there has been widespread adoption of steroids in the care of critically ill patients with COVID-19," particularly in countries with limited resources.

"This meta-analysis adds further confidence" in the use of steroids in these patients, she added.

The National Institutes of Health, the Infectious Diseases Society and other groups also have issued recommendations for the use of steroids in critically ill COVID-19 patients.

Even before the coronavirus pandemic, doctors were studying steroids' abilities to reduce inflammation and improve outcomes in patients with acute respiratory distress syndrome and septic shock. But many of the findings had been inconclusive.

The use of steroids in COVID-19 patients with mild to moderate infections is not recommended. If steroids are administered too early in disease progression, doctors fear they may dampen the immune system's natural fighting abilities and lead to worse outcomes.

If steroids are administered when inflammation levels begin to spike, there may some benefit – especially if the patient also is treated with an antiviral medication, Bhadelia said. But more data is needed to confirm this theory.

The researchers involved in the WHO analysis emphasized that steroids aren't a cure for COVID-19. Prevention and treatment strategies are still needed. 

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