Systemic corticosteroids for the treatment of COVID-19: Equity-related analyses and update on evidence

• Published in: Cochrane database of systematic reviews 2022-11, Vol.11, p.CD014963
• Main Authors: Wagner, Carina, Griesel, Mirko, Mikolajewska, Agata, Metzendorf, Maria-Inti, Fischer, Anna-Lena, Stegemann, Miriam, Spagl, Manuel, Nair, Avinash Anil, Daniel, Jefferson, Fichtner, Falk, Skoetz, Nicole
• Format: Article
• Language: English
• Subjects: Adrenal Cortex Hormones - adverse effects; Aged; Aged, 80 and over; COVID-19 Drug Treatment; Dexamethasone - adverse effects; Humans; Invasive Fungal Infections; Methylprednisolone; Post-Acute COVID-19 Syndrome; Randomized Controlled Trials as Topic
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD014963.pub2

Systemic corticosteroids are used to treat people with COVID-19 because they counter hyper-inflammation. Existing evidence syntheses suggest a slight benefit on mortality. Nonetheless, size of effect, optimal therapy regimen, and selection of patients who are likely to benefit most are factors that remain to be evaluated. To assess whether and at which doses systemic corticosteroids are effective and safe in the treatment of people with COVID-19, to explore equity-related aspects in subgroup analyses, and to keep up to date with the evolving evidence base using a living systematic review approach. We searched the Cochrane COVID-19 Study Register (which includes PubMed, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies to 6 January 2022. We included randomised controlled trials (RCTs) that evaluated systemic corticosteroids for people with COVID-19. We included any type or dose of systemic corticosteroids and the following comparisons: systemic corticosteroids plus standard care versus standard care, different types, doses and timings (early versus late) of corticosteroids. We excluded corticosteroids in combination with other active substances versus standard care, topical or inhaled corticosteroids, and corticosteroids for long-COVID treatment. We followed standard Cochrane methodology. To assess the risk of bias in included studies, we used the Cochrane 'Risk of bias' 2 tool for RCTs. We rated the certainty of the evidence using the GRADE approach for the following outcomes: all-cause mortality up to 30 and 120 days, discharged alive (clinical improvement), new need for invasive mechanical ventilation or death (clinical worsening), serious adverse events, adverse events, hospital-acquired infections, and invasive fungal infections. We included 16 RCTs in 9549 participants, of whom 8271 (87%) originated from high-income countries. A total of 4532 participants were randomised to corticosteroid arms and the majority received dexamethasone (n = 3766). These studies included participants mostly older than 50 years and male. We also identified 42 ongoing and 23 completed studies lacking published results or relevant information on the study design. Hospitalised individuals with a confirmed or suspected diagnosis of symptomatic COVID-19 Systemic corticosteroids plus standard care ve