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Abdelkader AA, Alsfouk BA, Saleh A, Abdelrahim MEA, Saeed H. Comparative Efficacy of Inhaled and Intravenous Corticosteroids in Managing COVID-19-Related Acute Respiratory Distress Syndrome. Pharmaceutics 2024; 16:952. [PMID: 39065649 PMCID: PMC11279829 DOI: 10.3390/pharmaceutics16070952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/07/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition in which the lungs fail to provide sufficient oxygen to the body's vital organs. It is commonly associated with COVID-19 patients. Severe cases of COVID-19 can lead to lung damage and organ failure due to an immune response in the body. To mitigate these effects, corticosteroids, which are known for their anti-inflammatory properties, have been suggested as a potential treatment option. The primary focus of this study was to assess the impact of various corticosteroid administration methods on the outcomes of patients with COVID-19. Methods: The current study was conducted on COVID-19 patients divided into three groups. The first group was administered 6 mg of intravenous (IV) dexamethasone; the second group received 1 mg/kg of IV methylprednisolone (methylprednisolone); and the third group received budesonide respirable solution at a dosage of 1mg twice daily. The neubilizer used was a vibrating mesh nebulizer (VMN). All patients received standard care. We found that dexamethasone administered intravenously led to a significant reduction in C-reactive protein levels, surpassing the effectiveness of both IV methylprednisolone and inhaled budesonide. Oxygen saturation without mask change over time showed statistically significant differences (p = 0.004) in favor of the budesonide and dexamethasone groups for all days. Individuals who received methylprednisolone showed a significant decrease in mortality rate and an extended survival duration, with statistical significance observed at p = 0.024. The rest of the parameters, including ferritin, lymphocytes, total leukocyte count, platelets, hemoglobin, urea, serum potassium, serum sodium, serum creatinine, serum glutamic-pyruvic transaminase, serum glutamic-oxaloacetic transaminase, uric acid, albumin, globulin, erythrocyte sedimentation rate, international normalized ratio, oxygen saturation with flow, and oxygen flow, showed no statistically significant differences between the three drugs. In conclusion, treatment with IV methylprednisolone (1 mg/kg) resulted in a shorter hospital stay, decreased reliance on ventilation, and improved health outcomes for COVID-19 patients compared to using dexamethasone at a daily dosage of 6 mg or budesonide respirable solution at a dosage of 1mg twice daily.
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Affiliation(s)
- Ahmed A. Abdelkader
- Clinical Pharmacy Department, Faculty of Pharmacy, Heliopolis University, Cairo 11765, Egypt
| | - Bshra A. Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (B.A.A.); (A.S.)
| | - Asmaa Saleh
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (B.A.A.); (A.S.)
| | - Mohamed E. A. Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt; (M.E.A.A.); (H.S.)
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt; (M.E.A.A.); (H.S.)
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Bhimraj A, Morgan RL, Shumaker AH, Baden L, Cheng VCC, Edwards KM, Gallagher JC, Gandhi RT, Muller WJ, Nakamura MM, O’Horo JC, Shafer RW, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022). Clin Infect Dis 2024; 78:e250-e349. [PMID: 36063397 PMCID: PMC9494372 DOI: 10.1093/cid/ciac724] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/07/2023] Open
Abstract
There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.
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Affiliation(s)
- Adarsh Bhimraj
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Amy Hirsch Shumaker
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Vincent Chi Chung Cheng
- Queen Mary Hospital, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center,Nashville, Tennessee
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, Pennsylvania
| | - Rajesh T Gandhi
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - William J Muller
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, Illinois
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John C O’Horo
- Division of Infectious Diseases, Joint Appointment Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert W Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Yngve Falck-Ytter
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
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Wagner C, Griesel M, Mikolajewska A, Metzendorf MI, Fischer AL, Stegemann M, Spagl M, Nair AA, Daniel J, Fichtner F, Skoetz N. Systemic corticosteroids for the treatment of COVID-19: Equity-related analyses and update on evidence. Cochrane Database Syst Rev 2022; 11:CD014963. [PMID: 36385229 PMCID: PMC9670242 DOI: 10.1002/14651858.cd014963.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND 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. OBJECTIVES 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. SEARCH METHODS 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. SELECTION CRITERIA 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. DATA COLLECTION AND ANALYSIS 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. MAIN RESULTS 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 versus standard care plus/minus placebo We included 11 RCTs (8019 participants), one of which did not report any of our pre-specified outcomes and thus our analyses included outcome data from 10 studies. Systemic corticosteroids plus standard care compared to standard care probably reduce all-cause mortality (up to 30 days) slightly (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.84 to 0.97; 7898 participants; estimated absolute effect: 274 deaths per 1000 people not receiving systemic corticosteroids compared to 246 deaths per 1000 people receiving the intervention (95% CI 230 to 265 per 1000 people); moderate-certainty evidence). The evidence is very uncertain about the effect on all-cause mortality (up to 120 days) (RR 0.74, 95% CI 0.23 to 2.34; 485 participants). The chance of clinical improvement (discharged alive at day 28) may slightly increase (RR 1.07, 95% CI 1.03 to 1.11; 6786 participants; low-certainty evidence) while the risk of clinical worsening (new need for invasive mechanical ventilation or death) may slightly decrease (RR 0.92, 95% CI 0.84 to 1.01; 5586 participants; low-certainty evidence). For serious adverse events (two RCTs, 678 participants), adverse events (three RCTs, 447 participants), hospital-acquired infections (four RCTs, 598 participants), and invasive fungal infections (one study, 64 participants), we did not perform any analyses beyond the presentation of descriptive statistics due to very low-certainty evidence (high risk of bias, heterogeneous definitions, and underreporting). Different types, dosages or timing of systemic corticosteroids We identified one RCT (86 participants) comparing methylprednisolone to dexamethasone, thus the evidence is very uncertain about the effect of methylprednisolone on all-cause mortality (up to 30 days) (RR 0.51, 95% CI 0.24 to 1.07; 86 participants). None of the other outcomes of interest were reported in this study. We included four RCTs (1383 participants) comparing high-dose dexamethasone (12 mg or higher) to low-dose dexamethasone (6 mg to 8 mg). High-dose dexamethasone compared to low-dose dexamethasone may reduce all-cause mortality (up to 30 days) (RR 0.87, 95% CI 0.73 to 1.04; 1269 participants; low-certainty evidence), but the evidence is very uncertain about the effect of high-dose dexamethasone on all-cause mortality (up to 120 days) (RR 0.93, 95% CI 0.79 to 1.08; 1383 participants) and it may have little or no impact on clinical improvement (discharged alive at 28 days) (RR 0.98, 95% CI 0.89 to 1.09; 200 participants; low-certainty evidence). Studies did not report data on clinical worsening (new need for invasive mechanical ventilation or death). For serious adverse events, adverse events, hospital-acquired infections, and invasive fungal infections, we did not perform analyses beyond the presentation of descriptive statistics due to very low-certainty evidence. We could not identify studies for comparisons of different timing and systemic corticosteroids versus other active substances. Equity-related subgroup analyses We conducted the following subgroup analyses to explore equity-related factors: sex, age (< 70 years; ≥ 70 years), ethnicity (Black, Asian or other versus White versus unknown) and place of residence (high-income versus low- and middle-income countries). Except for age and ethnicity, no evidence for differences could be identified. For all-cause mortality up to 30 days, participants younger than 70 years seemed to benefit from systemic corticosteroids in comparison to those aged 70 years and older. The few participants from a Black, Asian, or other minority ethnic group showed a larger estimated effect than the many White participants. Outpatients with asymptomatic or mild disease There are no studies published in populations with asymptomatic infection or mild disease. AUTHORS' CONCLUSIONS Systemic corticosteroids probably slightly reduce all-cause mortality up to 30 days in people hospitalised because of symptomatic COVID-19, while the evidence is very uncertain about the effect on all-cause mortality up to 120 days. For younger people (under 70 years of age) there was a potential advantage, as well as for Black, Asian, or people of a minority ethnic group; further subgroup analyses showed no relevant effects. Evidence related to the most effective type, dose, or timing of systemic corticosteroids remains immature. Currently, there is no evidence on asymptomatic or mild disease (non-hospitalised participants). Due to the low to very low certainty of the current evidence, we cannot assess safety adequately to rule out harmful effects of the treatment, therefore there is an urgent need for good-quality safety data. Findings of equity-related subgroup analyses should be interpreted with caution because of their explorative nature, low precision, and missing data. We identified 42 ongoing and 23 completed studies lacking published results or relevant information on the study design, suggesting there may be possible changes of the effect estimates and certainty of the evidence in the future.
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Affiliation(s)
- Carina Wagner
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna-Lena Fischer
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Manuel Spagl
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Avinash Anil Nair
- Department of Respiratory Medicine, Christian Medical College, Vellore, India
| | - Jefferson Daniel
- Department of Pulmonary Medicine, Christian Medical College, Vellore, India
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Islam MZ, Hossain SI, Deplazes E, Luo Z, Saha SC. The concentration-dependent effect of hydrocortisone on the structure of model lung surfactant monolayer by using an in silico approach. RSC Adv 2022; 12:33313-33328. [PMID: 36506480 PMCID: PMC9680622 DOI: 10.1039/d2ra05268g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022] Open
Abstract
Understanding the adsorption mechanism of corticosteroids in the lung surfactant requires the knowledge of corticosteroid molecular interactions with lung surfactant monolayer (LSM). We employed coarse-grained molecular dynamics simulation to explore the action of hydrocortisone on an LSM comprised of a phospholipid, cholesterol and surfactant protein. The structural and dynamical morphology of the lung surfactant monolayer at different surface tensions were investigated to assess the monolayer compressibility. The simulations were also conducted at the two extreme ends of breathing cycles: exhalation (0 mN m-1 surface tension) and inhalation (20 mN m-1 surface tension). The impact of surface tension and hydrocortisone concentration on the monolayer compressibility and stability are significant, resulting the monolayer expansion at higher surface tension. However, at low surface tension, the highly compressed monolayer induces monolayer instability in the presence of the drug due to the accumulation of surfactant protein and drug. The constant area per lipid simulation results demonstrate that the surface pressure-area isotherms show a decrease in area-per-lipid with increased drug concentration. The drug-induced expansion causes considerable instability in the monolayer after a specific drug concentration is attained at inhalation breathing condition, whereas, for exhalation breathing, the monolayer gets more compressed, causing the LSM to collapse. The monolayer collapse occurs for inhalation due to the higher drug concentration, whereas for exhalation due to the accumulation of surfactant proteins and drugs. The findings from this study will aid in enhancing the knowledge of molecular interactions of corticosteroid drugs with lung surfactants to treat respiratory diseases.
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Affiliation(s)
- Mohammad Zohurul Islam
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
| | - Sheikh I Hossain
- School of Life Sciences, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
| | - E Deplazes
- School of Life Sciences, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
| | - Zhen Luo
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
| | - Suvash C Saha
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney 15 Broadway Ultimo 2007 NSW Australia
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Microbiological and Clinical Findings of SARS-CoV-2 Infection after 2 Years of Pandemic: From Lung to Gut Microbiota. Diagnostics (Basel) 2022; 12:diagnostics12092143. [PMID: 36140544 PMCID: PMC9498253 DOI: 10.3390/diagnostics12092143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 01/08/2023] Open
Abstract
Early recognition and prompt management are crucial for improving survival in COVID-19 patients, and after 2 years of the pandemic, many efforts have been made to obtain an early diagnosis. A key factor is the use of fast microbiological techniques, considering also that COVID-19 patients may show no peculiar signs and symptoms that may differentiate COVID-19 from other infective or non-infective diseases. These techniques were developed to promptly identify SARS-CoV-2 infection and to prevent viral spread and transmission. However, recent data about clinical, radiological and laboratory features of COVID-19 at time of hospitalization could help physicians in early suspicion of SARS-CoV-2 infection and distinguishing it from other etiologies. The knowledge of clinical features and microbiological techniques will be crucial in the next years when the endemic circulation of SARS-CoV-2 will be probably associated with clusters of infection. In this review we provide a state of the art about new advances in microbiological and clinical findings of SARS-CoV-2 infection in hospitalized patients with a focus on pulmonary and extrapulmonary characteristics, including the role of gut microbiota.
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Moeinafshar A, Yazdanpanah N, Rezaei N. Immune-based therapeutic approaches in COVID-19. Biomed Pharmacother 2022; 151:113107. [PMID: 35594701 PMCID: PMC9108029 DOI: 10.1016/j.biopha.2022.113107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a member of the Coronaviridae family. On March 11, 2020 the World Health Organization (WHO) has named the newly emerged rapidly-spreading epidemic as a pandemic. Besides the risk-reduction measures such as physical and social distancing and vaccination, a wide range of treatment modalities have been developed; aiming to fight the disease. The immune system is known as a double-edged sword in COVID-19 pathogenesis, with respect to its role in eliminating the pathogen and in inducing complications such as cytokine storm syndrome. Hence, immune-based therapeutic approaches have become an interesting field of COVID-19 research, including corticosteroids, intravenous immunoglobulins (IVIG), interferon therapy, and more COVID-19-specific approaches such as anti-SARS-CoV-2-monoclonal antibodies. Herein, we did a comprehensive review on immune-based therapeutic approaches for COVID-19. DATA AVAILABILITY STATEMENT: Not applicable.
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Affiliation(s)
- Aysan Moeinafshar
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Niloufar Yazdanpanah
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran,Correspondence to: Children's Medical Center Hospital, Dr. Qarib St, Keshavarz Blvd, Tehran 14194, Iran
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Munch MW, Granholm A, Kjær MN, Aksnes TS, Sølling CG, Christensen S, Perner A. Long-term mortality and health-related quality of life in the COVID STEROID trial. Acta Anaesthesiol Scand 2022; 66:543-545. [PMID: 35067914 DOI: 10.1111/aas.14029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/15/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Marie Warrer Munch
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Tobias Saxtorph Aksnes
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | | | - Steffen Christensen
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Intensive Care Aarhus University Hospital Aarhus N Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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Fraile Navarro D, Tendal B, Tingay D, Vasilunas N, Anderson L, Best J, Burns P, Cheyne S, Craig SS, Erickson SJ, Fancourt NSS, Goff Z, Kapuya V, Keyte C, Malyon L, McDonald S, White H, Wurzel D, Bowen AC, McMullan B. Clinical care of children and adolescents with COVID-19: recommendations from the National COVID-19 Clinical Evidence Taskforce. Med J Aust 2022; 216:255-263. [PMID: 34689329 PMCID: PMC8661691 DOI: 10.5694/mja2.51305] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The epidemiology and clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are different in children and adolescents compared with adults. Although coronavirus disease 2019 (COVID-19) appears to be less common in children, with milder disease overall, severe complications may occur, including paediatric inflammatory multisystem syndrome (PIMS-TS). Recognising the distinct needs of this population, the National COVID-19 Clinical Evidence Taskforce formed a Paediatric and Adolescent Care Panel to provide living guidelines for Australian clinicians to manage children and adolescents with COVID-19 and COVID-19 complications. Living guidelines mean that these evidence-based recommendations are updated in near real time to give reliable, contemporaneous advice to Australian clinicians providing paediatric care. MAIN RECOMMENDATIONS To date, the Taskforce has made 20 specific recommendations for children and adolescents, including definitions of disease severity, recommendations for therapy, respiratory support, and venous thromboembolism prophylaxis for COVID-19 and for the management of PIMS-TS. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES The Taskforce currently recommends corticosteroids as first line treatment for acute COVID-19 in children and adolescents who require oxygen. Tocilizumab could be considered, and remdesivir should not be administered routinely in this population. Non-invasive ventilation or high flow nasal cannulae should be considered in children and adolescents with hypoxaemia or respiratory distress unresponsive to low flow oxygen if appropriate infection control measures can be used. Children and adolescents with PIMS-TS should be managed by a multidisciplinary team. Intravenous immunoglobulin and corticosteroids, with concomitant aspirin and thromboprophylaxis, should be considered for the treatment of PIMS-TS. The latest updates and full recommendations are available at www.covid19evidence.net.au.
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Affiliation(s)
- David Fraile Navarro
- Cochrane AustraliaMonash UniversityMelbourneVIC
- Centre for Health InformaticsAustralian Institute of Health InnovationMacquarie UniversitySydneyNSW
| | | | - David Tingay
- Murdoch Children’s Research InstituteMelbourneVIC
- Royal Children’s Hospital MelbourneMelbourneVIC
| | - Nan Vasilunas
- Women’s and Children’s Health NetworkWomen’s and Children’s Hospital AdelaideAdelaideSA
| | - Lorraine Anderson
- Kimberley Aboriginal Medical Services CouncilBroomeWA
- Junction Street Family PracticeSydneyNSW
| | - James Best
- Junction Street Family PracticeSydneyNSW
| | - Penelope Burns
- Australian National UniversityCanberraACT
- Northern Beaches HospitalSydneyNSW
- Western Sydney UniversitySydneyNSW
| | - Saskia Cheyne
- Cochrane AustraliaMonash UniversityMelbourneVIC
- NHMRC Clinical Trials CentreUniversity of SydneySydneyNSW
| | - Simon S Craig
- Monash UniversityMelbourneVIC
- Monash Medical CentreMonash HealthMelbourneVIC
| | | | | | - Zoy Goff
- Perth Children’s HospitalPerthWA
| | - Vimbai Kapuya
- Charles Darwin UniversityDarwinNT
- Australian College of Rural and Remote MedicineBrisbaneQLD
| | - Catherine Keyte
- Queensland Children’s HospitalBrisbaneQLD
- Australian College of NursingCanberraACT
| | | | | | - Heath White
- Cochrane AustraliaMonash UniversityMelbourneVIC
| | - Danielle Wurzel
- Murdoch Children’s Research InstituteMelbourneVIC
- Royal Children’s Hospital MelbourneMelbourneVIC
| | - Asha C Bowen
- Perth Children’s HospitalPerthWA
- Wesfarmers Centre for Vaccines and Infectious DiseasesTelethon Kids InstitutePerthWA
| | - Brendan McMullan
- Sydney Children’s HospitalRandwick, SydneyNSW
- University of New South WalesSydneyNSW
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9
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Bartoletti M, Azap O, Barac A, Bussini L, Ergonul O, Krause R, Paño-Pardo JR, Power NR, Sibani M, Szabo BG, Tsiodras S, Verweij PE, Zollner-Schwetz I, Rodríguez-Baño J. ESCMID COVID-19 living guidelines: drug treatment and clinical management. Clin Microbiol Infect 2022; 28:222-238. [PMID: 34823008 PMCID: PMC8606314 DOI: 10.1016/j.cmi.2021.11.007] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 02/08/2023]
Abstract
SCOPE In January 2021, the ESCMID Executive Committee decided to launch a new initiative to develop ESCMID guidelines on several COVID-19-related issues, including treatment of COVID-19. METHODS An ESCMID COVID-19 guidelines task force was established by the ESCMID Executive Committee. A small group was established, half appointed by the chair, and the remaining selected with an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the PICO (population, intervention, comparison, outcome) format was developed at the beginning of the process. For each PICO, two panel members performed a literature search with a third panellist involved in case of inconsistent results. Voting was based on the GRADE approach. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS A synthesis of the available evidence and recommendations is provided for each of the 15 PICOs, which cover use of hydroxychloroquine, bamlanivimab alone or in combination with etesevimab, casirivimab combined with imdevimab, ivermectin, azithromycin and empirical antibiotics, colchicine, corticosteroids, convalescent plasma, favipiravir, remdesivir, tocilizumab and interferon β-1a, as well as the utility of antifungal prophylaxis and enoxaparin. In general, the panel recommended against the use of hydroxychloroquine, ivermectin, azithromycin, colchicine and interferon β-1a. Conditional recommendations were given for the use of monoclonal antibodies in high-risk outpatients with mild-moderate COVID-19, and remdesivir. There was insufficient evidence to make a recommendation for use of favipiravir and antifungal prophylaxis, and it was recommended that antibiotics should not be routinely prescribed in patients with COVID-19 unless bacterial coinfection or secondary infection is suspected or confirmed. Tocilizumab and corticosteroids were recommended for treatment of severe COVID-19 but not in outpatients with non-severe COVID-19. SCOPE The aim of the present guidance is to provide evidence-based recommendations for management of adults with coronavirus disease 2019 (COVID-19). More specifically, the goal is to aid clinicians managing patients with COVID-19 at various levels of severity including outpatients, hospitalized patients, and those admitted to intensive care unit. Considering the composition of the panel, mostly clinical microbiologists or infectious disease specialists with no pulmonology or intensive care background, we focus only on pharmacological treatment and do not give recommendations on oxygen supplement/support. Similarly, as no paediatricians were included in the panel; the recommendations are only for adult patients with COVID-19. Considering the current literature, no guidance was given for special populations such as the immunocompromised.
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Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Ozlem Azap
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, Clinical Centre of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Linda Bussini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Onder Ergonul
- Koc University Research Centre for Infectious Diseases, Istanbul, Turkey
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - José Ramón Paño-Pardo
- Fundación Instituto de Investigación Sanitaria Aragón (IIS Aragón), Biomedical Research Centre of Aragón (CIBA), Zaragoza, Spain; Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Nicholas R Power
- Royal College of Physicians of Ireland, Setanta House, Setanta Pl, Dublin, Ireland
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Balint Gergely Szabo
- South Pest Central Hospital, National Institute of Haematology and Infectious Diseases, Budapest, Hungary; School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Paul E Verweij
- Department of Medical Microbiology and Radboudumc-CWZ Centre of Expertise for Mycology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ines Zollner-Schwetz
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases and Microbiology Virgen Macarena University Hospital and Department of Medicine, University of Seville, Institute of Biomedicine of Seville, Seville, Spain
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10
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Hu S, Jiang S, Qi X, Bai R, Ye XY, Xie T. Races of small molecule clinical trials for the treatment of COVID-19: An up-to-date comprehensive review. Drug Dev Res 2021; 83:16-54. [PMID: 34762760 PMCID: PMC8653368 DOI: 10.1002/ddr.21895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
The coronavirus disease‐19 (COVID‐19) pandemic has become a global threat since its first outbreak at the end of 2019. Several review articles have been published recently, focusing on the aspects of target biology, drug repurposing, and mechanisms of action (MOAs) for potential treatment. This review gathers all small molecules currently in active clinical trials, categorizes them into six sub‐classes, and summarizes their clinical progress. The aim is to provide the researchers from both pharmaceutical industries and academic institutes with the handful information and dataset to accelerate their research programs in searching effective small molecule therapy for treatment of COVID‐19.
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Affiliation(s)
- Suwen Hu
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China.,Hangzhou Huadong Medicine Group, Pharmaceutical Research Institute Co. Ltd., Hangzhou, China.,Department of Chemistry and Biochemistry Los Angeles, University of California, Los Angeles, California, USA
| | - Songwei Jiang
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Xiang Qi
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Renren Bai
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Xiang-Yang Ye
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Tian Xie
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
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11
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Efficacy and Safety of Immunomodulators in Patients with COVID-19: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Infect Dis Ther 2021; 11:231-248. [PMID: 34757578 PMCID: PMC8579415 DOI: 10.1007/s40121-021-00545-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/30/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Many immunomodulators have been studied in clinical trials for the treatment of coronavirus disease 2019 (COVID-19). However, data identifying the most effective and safest treatment are lacking. We conducted a systematic review and network meta-analysis to rank immunomodulators in the treatment of COVID-19 according to their efficacy and safety. Methods Published and peer-reviewed randomized controlled trials assessing the efficacy of immunomodulators in hospitalized patients with COVID-19 were searched up to June 30, 2021. Direct and network meta-analyses were applied to assess the outcomes. The probability of efficacy and safety was estimated, and the drugs were awarded a numerical ranking. Results Twenty-six studies were eligible. Compared with standard of care, dexamethasone and tocilizumab had significantly lower mortality rates with pooled risk ratios (RRs) of 0.91 (95% confidence interval [CI] 0.84–0.99) and 0.88 (95% CI 0.82–0.96), respectively. Meanwhile, the most effective corticosteroid, interleukin-6 antagonist, and Janus kinase (JAK) inhibitor were hydrocortisone, sarilumab, and ruxolitinib, respectively. However, when superimposed infection was considered, ruxolitinib was the best treatment followed by baricitinib. Moreover, methylprednisolone had the worst combined efficacy and safety among the examined treatments. Conclusions Overall, immunomodulators were more effective than standard of care. Important differences exist among immunomodulators regarding both efficacy and safety in favor of ruxolitinib and baricitinib. Further well-conducted randomized controlled trials should focus on JAK inhibitors. Methylprednisolone use should be discouraged because of its poor efficacy and high risk of superimposed infection. Trial Registration PROSPERO registration identifier CRD 42021257421. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00545-0.
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12
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Patel VK, Shirbhate E, Patel P, Veerasamy R, Sharma PC, Rajak H. Corticosteroids for treatment of COVID-19: effect, evidence, expectation and extent. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2021; 10:78. [PMID: 34751250 PMCID: PMC8567120 DOI: 10.1186/s43088-021-00165-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) announced the COVID-19 occurrence as a global pandemic in March 2020. The treatment of SARS-CoV-2 patients is based on the experience gained from SARS-CoV and MERS-CoV infection during 2003. There is no clinically accepted therapeutic drug(s) accessible yet for the treatment of COVID-19. MAIN BODY Corticosteroids, i.e., dexamethasone, methylprednisolone, hydrocortisone and prednisone are used alone or in combination for the treatment of moderate, severe and critically infected COVID-19 patients who are hospitalized and require supplemental oxygen as per current management strategies and guidelines for COVID-19 published by the National Institutes of Health. Corticosteroids are recorded in the WHO model list of essential medicines and are easily accessible worldwide at a cheaper cost in multiple formulations and various dosage forms. Corticosteroid can be used in all age group of patients, i.e., children, adult, elderly and during pregnancy or breastfeeding women. Corticosteroids have potent anti-inflammatory and immunosuppressive effects in both primary and secondary immune cells, thereby reducing the generation of proinflammatory cytokines and chemokines and lowering the activation of T cells, monocytes and macrophages. The corticosteroids should not be used in the treatment of non-severe COVID-19 patients because corticosteroids suppress the immune response and reduce the symptoms and associated side effects such as slow recovery, bacterial infections, hypokalemia, mucormycosis and finally increase the chances of death. CONCLUSION Intensive research on corticosteroid therapy in COVID-19 treatment is urgently needed to elucidate their mechanisms and importance in contributing toward successful prevention and treatment approaches. Hence, this review emphasizes on recent advancement on corticosteroid therapy for defining their importance in overcoming SARS-CoV-2 pandemic, their mechanism, efficacy and extent of corticosteroids in the treatment of COVID-19 patients.
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Affiliation(s)
- Vijay K. Patel
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Ekta Shirbhate
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Preeti Patel
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Ravichandran Veerasamy
- Faculty of Pharmacy, AIMST University, 08100 Semeling, Bedong, Kedah Darul Aman Malaysia
| | - Prabodh C. Sharma
- Department of Pharmaceutical Chemistry, Delhi Pharmaceutical Sciences and Research University, MB Road, Pushp Vihar, New Delhi, 110 017 India
| | - Harish Rajak
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
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13
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Munch MW, Meyhoff TS, Helleberg M, Kjær MN, Granholm A, Hjortsø CJS, Jensen TS, Møller MH, Hjortrup PB, Wetterslev M, Vesterlund GK, Russell L, Jørgensen VL, Kristiansen KT, Benfield T, Ulrik CS, Andreasen AS, Bestle MH, Poulsen LM, Hildebrandt T, Knudsen LS, Møller A, Sølling CG, Brøchner AC, Rasmussen BS, Nielsen H, Christensen S, Strøm T, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Venkatesh B, Hammond N, Jha V, Myatra SN, Jensen MQ, Leistner JW, Mikkelsen VS, Svenningsen JS, Laursen SB, Hatley EV, Kristensen CM, Al‐Alak A, Clapp E, Jonassen TB, Bjerregaard CL, Østerby NCH, Jespersen MM, Abou‐Kassem D, Lassen ML, Zaabalawi R, Daoud MM, Abdi S, Meier N, Cour K, Derby CB, Damlund BR, Laigaard J, Andersen LL, Mikkelsen J, Jensen JLS, Rasmussen AH, Arnerlöv E, Lykke M, Holst‐Hansen MZB, Tøstesen BW, Schwab J, Madsen EK, Gluud C, Lange T, Perner A. Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia: The COVID STEROID randomised, placebo-controlled trial. Acta Anaesthesiol Scand 2021; 65:1421-1430. [PMID: 34138478 PMCID: PMC8441888 DOI: 10.1111/aas.13941] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/05/2021] [Indexed: 12/20/2022]
Abstract
Background In the early phase of the pandemic, some guidelines recommended the use of corticosteroids for critically ill patients with COVID‐19, whereas others recommended against the use despite lack of firm evidence of either benefit or harm. In the COVID STEROID trial, we aimed to assess the effects of low‐dose hydrocortisone on patient‐centred outcomes in adults with COVID‐19 and severe hypoxia. Methods In this multicentre, parallel‐group, placebo‐controlled, blinded, centrally randomised, stratified clinical trial, we randomly assigned adults with confirmed COVID‐19 and severe hypoxia (use of mechanical ventilation or supplementary oxygen with a flow of at least 10 L/min) to either hydrocortisone (200 mg/d) vs a matching placebo for 7 days or until hospital discharge. The primary outcome was the number of days alive without life support at day 28 after randomisation. Results The trial was terminated early when 30 out of 1000 participants had been enrolled because of external evidence indicating benefit from corticosteroids in severe COVID‐19. At day 28, the median number of days alive without life support in the hydrocortisone vs placebo group were 7 vs 10 (adjusted mean difference: −1.1 days, 95% CI −9.5 to 7.3, P = .79); mortality was 6/16 vs 2/14; and the number of serious adverse reactions 1/16 vs 0/14. Conclusions In this trial of adults with COVID‐19 and severe hypoxia, we were unable to provide precise estimates of the benefits and harms of hydrocortisone as compared with placebo as only 3% of the planned sample size were enrolled. Trial registration: ClinicalTrials.gov: NCT04348305. European Union Drug Regulation Authorities Clinical Trials (EudraCT) Database: 2020‐001395‐15.
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14
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Thakur M, Datusalia AK, Kumar A. Use of steroids in COVID-19 patients: A meta-analysis. Eur J Pharmacol 2021; 914:174579. [PMID: 34678244 PMCID: PMC8525014 DOI: 10.1016/j.ejphar.2021.174579] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/07/2021] [Accepted: 10/18/2021] [Indexed: 12/12/2022]
Abstract
Background Emerging reports have shown the benefits of steroids in hospitalized COVID-19 patients as life-saving drugs. However, the use of steroids in COVID-19 patients is confusing among many physicians. Aim The aim of the current study was to find out the exact association of steroids in the deaths of COVID-19 patients. Methods The relevant studies were searched in PubMed, Google scholar, and Clinical trials registries till May 25, 2021 and sorted out based on inclusion and exclusion criteria. The quality of studies was assessed using a standard scale. The pooled odds ratio was calculated with a 95% confidence interval. The sensitivity and sub-group analyses were also done. The publication bias was assessed qualitatively. The Rev Man 5 was used for all analyses with a random-effect model. Results The quantitative analysis was done with 9922 patients (6265-male and 3657-females) from 21 relevant studies. The pooled estimate results i.e. 0.52 [0.34, 0.80] have shown a significant reduction in deaths of COVID-19 patients in the steroidal group as compared to the non-steroidal group. The sensitivity analyses did not alter our conclusions. In subgroup analysis, methylprednisolone has shown a significant reduction in deaths of COVID-19 patients as compared to the non-steroidal group, however, more clinical evidence is required for dexamethasone and hydrocortisone. Conclusion The use of steroids in hospitalized COVID-19 patients is useful to reduce deaths.
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Affiliation(s)
- Manisha Thakur
- Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli, 226002, India
| | - Ashok Kumar Datusalia
- Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli, 226002, India; Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli, 226002, India
| | - Anoop Kumar
- Department of Pharmacology, Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, 110017, India.
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15
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Picchianti Diamanti A, Rosado MM, Nicastri E, Sesti G, Pioli C, Laganà B. Severe Acute Respiratory Syndrome Coronavirus-2 Infection and Autoimmunity 1 Year Later: The Era of Vaccines. Front Immunol 2021; 12:708848. [PMID: 34659200 PMCID: PMC8515900 DOI: 10.3389/fimmu.2021.708848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/27/2021] [Indexed: 12/15/2022] Open
Abstract
Impressive efforts have been made by researchers worldwide in the development of target vaccines against the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and in improving the management of immunomodulating agents. Currently, different vaccine formulations, such as viral vector, mRNA, and protein-based, almost all directed toward the spike protein that includes the domain for receptor binding, have been approved. Although data are not conclusive, patients affected by autoimmune rheumatic diseases (ARDs) seem to have a slightly higher disease prevalence, risk of hospitalization, and death from coronavirus disease-2019 (COVID-19) than the general population. Therefore, ARD patients, under immunosuppressive agents, have been included among the priority target groups for vaccine administration. However, specific cautions are needed to optimize vaccine safety and effectiveness in these patients, such as modification in some of the ongoing immunosuppressive therapies and the preferential use of mRNA other than vector-based vaccines. Immunomodulating agents can be a therapeutic opportunity for the management of COVID-19 patients; however, their clinical impact depends on how they are handled. To place in therapy immunomodulating agents in the correct window of opportunity throughout the identification of surrogate markers of disease progression and host immune response is mandatory to optimize patient's outcome.
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Affiliation(s)
- Andrea Picchianti Diamanti
- Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Rome, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Pioli
- Laboratory of Biomedical Technologies, Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development, Rome, Italy
| | - Bruno Laganà
- Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
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16
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Chong WH, Saha BK, Neu KP. Comparing the clinical characteristics and outcomes of COVID-19-associate pulmonary aspergillosis (CAPA): a systematic review and meta-analysis. Infection 2021; 50:43-56. [PMID: 34570355 PMCID: PMC8475405 DOI: 10.1007/s15010-021-01701-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/14/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Invasive pulmonary aspergillosis has been increasingly recognized in COVID-19 patients, termed COVID-19-associate pulmonary aspergillosis (CAPA). Our meta-analysis aims to assess the clinical characteristics and outcomes of patients diagnosed with CAPA compared to those without CAPA. METHODS We searched the Pubmed, Cochrane Library, SCOPUS, and Web of Science databases for studies published between January 1, 2020 and August 1, 2021, containing comparative data of patients diagnosed with CAPA and those without CAPA. RESULTS Eight cohort studies involving 729 critically ill COVID-19 patients with comparative data were included. CAPA patients were older (mean age 66.58 vs. 59.25 years; P = 0.007) and had underlying chronic obstructive pulmonary disease (COPD) (13.7 vs. 6.1%; OR 2.75; P = 0.05). No differences in gender, body mass index (BMI), and comorbidities of diabetes and cancer were observed. CAPA patients were more likely to receive long-term corticosteroid treatment (15.0 vs. 5.3%; OR 3.53; P = 0.03). CAPA patients had greater severity of illness based on sequential organ failure assessment (SOFA) score with a higher all-cause in-hospital mortality rate (42.6 vs. 26.5%; OR 3.39; P < 0.001) and earlier ICU admission from illness onset (mean 11.00 vs. 12.00 days; P = 0.003). ICU length of stay (LOS), invasive mechanical ventilation (IMV) duration, the requirement of inotropic support and renal replacement therapy were comparable between the two groups. CONCLUSIONS CAPA patients are typically older with underlying COPD and received long-term corticosteroid treatment. Furthermore, CAPA is associated with higher SOFA scores, mortality, and earlier onset of ICU admission from illness onset.
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Affiliation(s)
- Woon Hean Chong
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, MO, 65775, USA
| | - Kristoffer P Neu
- Department of Pulmonary and Critical Care, Albany Stratton VA Medical Center, Albany, NY, 12208, USA
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17
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Pathak GA, Wendt FR, Goswami A, Koller D, De Angelis F, Polimanti R. ACE2 Netlas: In silico Functional Characterization and Drug-Gene Interactions of ACE2 Gene Network to Understand Its Potential Involvement in COVID-19 Susceptibility. Front Genet 2021; 12:698033. [PMID: 34512723 PMCID: PMC8429844 DOI: 10.3389/fgene.2021.698033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022] Open
Abstract
Angiotensin-converting enzyme-2 (ACE2) receptor has been identified as the key adhesion molecule for the transmission of the SARS-CoV-2. However, there is no evidence that human genetic variation in ACE2 is singularly responsible for COVID-19 susceptibility. Therefore, we performed an integrative multi-level characterization of genes that interact with ACE2 (ACE2-gene network) for their statistically enriched biological properties in the context of COVID-19. The phenome-wide association of 51 genes including ACE2 with 4,756 traits categorized into 26 phenotype categories, showed enrichment of immunological, respiratory, environmental, skeletal, dermatological, and metabolic domains (p < 4e-4). Transcriptomic regulation of ACE2-gene network was enriched for tissue-specificity in kidney, small intestine, and colon (p < 4.7e-4). Leveraging the drug-gene interaction database we identified 47 drugs, including dexamethasone and spironolactone, among others. Considering genetic variants within ± 10 kb of ACE2-network genes we identified miRNAs whose binding sites may be altered as a consequence of genetic variation. The identified miRNAs revealed statistical over-representation of inflammation, aging, diabetes, and heart conditions. The genetic variant associations in RORA, SLC12A6, and SLC6A19 genes were observed in genome-wide association study (GWAS) of COVID-19 susceptibility. We also report the GWAS-identified variant in 3p21.31 locus, serves as trans-QTL for RORA and RORC genes. Overall, functional characterization of ACE2-gene network highlights several potential mechanisms in COVID-19 susceptibility. The data can also be accessed at https://gpwhiz.github.io/ACE2Netlas/.
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Affiliation(s)
- Gita A. Pathak
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Frank R. Wendt
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Aranyak Goswami
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Dora Koller
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Flavio De Angelis
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
| | | | - Renato Polimanti
- Division of Human Genetics, Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States
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18
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Wagner C, Griesel M, Mikolajewska A, Mueller A, Nothacker M, Kley K, Metzendorf MI, Fischer AL, Kopp M, Stegemann M, Skoetz N, Fichtner F. Systemic corticosteroids for the treatment of COVID-19. Cochrane Database Syst Rev 2021; 8:CD014963. [PMID: 34396514 PMCID: PMC8406706 DOI: 10.1002/14651858.cd014963] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Systemic corticosteroids are used to treat people with COVID-19 because they counter hyper-inflammation. Existing evidence syntheses suggest a slight benefit on mortality. So far, systemic corticosteroids are one of the few treatment options for COVID-19. Nonetheless, size of effect, certainty of the evidence, optimal therapy regimen, and selection of patients who are likely to benefit most are factors that remain to be evaluated. OBJECTIVES To assess whether systemic corticosteroids are effective and safe in the treatment of people with COVID-19, and to keep up to date with the evolving evidence base using a living systematic review approach. SEARCH METHODS 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 16 April 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated systemic corticosteroids for people with COVID-19, irrespective of disease severity, participant age, gender or ethnicity. We included any type or dose of systemic corticosteroids. We included the following comparisons: systemic corticosteroids plus standard care versus standard care (plus/minus placebo), dose comparisons, timing comparisons (early versus late), different types of corticosteroids and systemic corticosteroids versus other active substances. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome or Middle East respiratory syndrome), corticosteroids in combination with other active substances versus standard care, topical or inhaled corticosteroids, and corticosteroids for long-COVID treatment. DATA COLLECTION AND ANALYSIS 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 evidence using the GRADE approach for the following outcomes: all-cause mortality, ventilator-free days, new need for invasive mechanical ventilation, quality of life, serious adverse events, adverse events, and hospital-acquired infections. MAIN RESULTS We included 11 RCTs in 8075 participants, of whom 7041 (87%) originated from high-income countries. A total of 3072 participants were randomised to corticosteroid arms and the majority received dexamethasone (n = 2322). We also identified 42 ongoing studies and 16 studies reported as being completed or terminated in a study registry, but without results yet. Hospitalised individuals with a confirmed or suspected diagnosis of symptomatic COVID-19 Systemic corticosteroids plus standard care versus standard care plus/minus placebo We included 10 RCTs (7989 participants), one of which did not report any of our pre-specified outcomes and thus our analysis included outcome data from nine studies. All-cause mortality (at longest follow-up available): systemic corticosteroids plus standard care probably reduce all-cause mortality slightly in people with COVID-19 compared to standard care alone (median 28 days: risk difference of 30 in 1000 participants fewer than the control group rate of 275 in 1000 participants; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.80 to 1.00; 9 RCTs, 7930 participants; moderate-certainty evidence). Ventilator-free days: corticosteroids may increase ventilator-free days (MD 2.6 days more than control group rate of 4 days, 95% CI 0.67 to 4.53; 1 RCT, 299 participants; low-certainty evidence). Ventilator-free days have inherent limitations as a composite endpoint and should be interpreted with caution. New need for invasive ventilation: the evidence is of very low certainty. Because of high risk of bias arising from deaths that occurred before ventilation we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics. Quality of life/neurological outcome: no data were available. Serious adverse events: we included data on two RCTs (678 participants) that evaluated systemic corticosteroids compared to standard care (plus/minus placebo); for adverse events and hospital-acquired infections, we included data on five RCTs (660 participants). Because of high risk of bias, heterogeneous definitions, and underreporting we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics (very low-certainty evidence). Different types, dosages or timing of systemic corticosteroids We identified one study that compared methylprednisolone with dexamethasone. The evidence for mortality and new need for invasive mechanical ventilation is very low certainty due to the small number of participants (n = 86). No data were available for the other outcomes. We did not identify comparisons of different dosages or timing. Outpatients with asymptomatic or mild disease Currently, there are no studies published in populations with asymptomatic infection or mild disease. AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that systemic corticosteroids probably slightly reduce all-cause mortality in people hospitalised because of symptomatic COVID-19. Low-certainty evidence suggests that there may also be a reduction in ventilator-free days. Since we are unable to adjust for the impact of early death on subsequent endpoints, the findings for ventilation outcomes and harms have limited applicability to inform treatment decisions. Currently, there is no evidence for asymptomatic or mild disease (non-hospitalised participants). There is an urgent need for good-quality evidence for specific subgroups of disease severity, for which we propose level of respiratory support at randomisation. This applies to the comparison or subgroups of different types and doses of corticosteroids, too. Outcomes apart from mortality should be measured and analysed appropriately taking into account confounding through death if applicable. We identified 42 ongoing and 16 completed but not published RCTs in trials registries suggesting possible changes of effect estimates and certainty of the evidence in the future. Most ongoing studies target people who need respiratory support at baseline. With the living approach of this review, we will continue to update our search and include eligible trials and published data.
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Affiliation(s)
- Carina Wagner
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anika Mueller
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Monika Nothacker
- AWMF Institute for Medical Knowledge Management, Marburg, Germany
| | - Karoline Kley
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna-Lena Fischer
- Department of Anaesthesia and Intensive care, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Marco Kopp
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
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19
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Granholm A, Kaas‐Hansen BS, Kjær MN, Anthon CT, Sivapalan P, Schjørring OL, Andersen LW, Mathiesen O, Strøm T, Jensen AKG, Perner A, Møller MH. Patient-important outcomes other than mortality in recent ICU trials: Protocol for a scoping review. Acta Anaesthesiol Scand 2021; 65:1002-1007. [PMID: 34089522 DOI: 10.1111/aas.13937] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomised clinical trials (RCTs) conducted in intensive care units (ICUs) frequently focus on all-cause mortality, but other patient-important outcomes are increasingly used and recommended. Their use, however, is not straightforward: choices and definitions, operationalisation of death, handling of missing data, choice of effect measures, and statistical analyses for these outcomes vary greatly. METHODS We will conduct a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We will search 10 selected general and speciality journals for RCTs conducted in adult ICU patients from 2018 and onwards reporting at least 1 patient-important outcome other than mortality (including days alive without life support/days alive and out of hospital-type outcomes, health-related quality of life, functional/cognitive/neurological outcomes, and other general patient-important outcomes). We will summarise data on outcome measures and definitions, assessment time points, proportions and handling of death, proportions and handling of missing data, and effect measures and statistical methods used for analysis. DISCUSSION The outlined scoping review will provide an overview of choices, definitions and handling of patient-important outcomes other than mortality in contemporary RCTs conducted in adult ICU patients. This may guide discussions with patients and relatives, the design of future RCTs, and research on optimal outcome choices and handling.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- NNF Center for Protein Research University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | | | - Carl Thomas Anthon
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Praleene Sivapalan
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Lars W. Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
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20
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Hertanto DM, Wiratama BS, Sutanto H, Wungu CDK. Immunomodulation as a Potent COVID-19 Pharmacotherapy: Past, Present and Future. J Inflamm Res 2021; 14:3419-3428. [PMID: 34321903 PMCID: PMC8312605 DOI: 10.2147/jir.s322831] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/05/2021] [Indexed: 12/15/2022] Open
Abstract
In the first year of its appearance, the 2019 coronavirus disease (COVID-19) has affected more than 150 million individuals and killed 3 million people worldwide. The pandemic has also triggered numerous global initiatives to tackle the newly emerging disease, including the development of SARS-CoV-2 vaccines and the attempt to discover potential pharmacological therapies. Nonetheless, despite the success of SARS-CoV-2 vaccine development, COVID-19 therapy remains challenging. Several repurposed drugs that were documented to be useful in small clinical trials have been shown to be ineffective in larger studies. Additionally, the pathophysiology of SARS-CoV-2 infection displayed the predominance of hyperinflammation and immune dysregulation in inducing multiorgan damage. Therefore, the potential benefits of both immune modulation and suppression in COVID-19 have been extensively discussed. Here, we reviewed the roles of immunomodulation as potential COVID-19 pharmacological modalities based on the existing data and proposed several new immunologic targets to be tested in the foreseeable future.
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Affiliation(s)
- Decsa Medika Hertanto
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia.,Department of Internal Medicine, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics, and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Henry Sutanto
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.,Department of Physiology and Pharmacology, State University of New York (SUNY) Downstate Health Sciences University, New York, NY, USA
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Airlangga University, Surabaya, Indonesia.,Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
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21
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Granholm A, Munch MW, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Kjær MN, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond N, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Gluud C, Lange T, Perner A. Higher vs Lower Doses of Dexamethasone in Patients with COVID-19 and Severe Hypoxia (COVID STEROID 2) trial: Protocol for a secondary Bayesian analysis. Acta Anaesthesiol Scand 2021; 65:702-710. [PMID: 33583027 PMCID: PMC8014670 DOI: 10.1111/aas.13793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) can lead to severe hypoxic respiratory failure and death. Corticosteroids decrease mortality in severely or critically ill patients with COVID-19. However, the optimal dose remains unresolved. The ongoing randomised COVID STEROID 2 trial investigates the effects of higher vs lower doses of dexamethasone (12 vs 6 mg intravenously daily for up to 10 days) in 1,000 adult patients with COVID-19 and severe hypoxia. METHODS This protocol outlines the rationale and statistical methods for a secondary, pre-planned Bayesian analysis of the primary outcome (days alive without life support at day 28) and all secondary outcomes registered up to day 90. We will use hurdle-negative binomial models to estimate the mean number of days alive without life support in each group and present results as mean differences and incidence rate ratios with 95% credibility intervals (CrIs). Additional count outcomes will be analysed similarly and binary outcomes will be analysed using logistic regression models with results presented as probabilities, relative risks and risk differences with 95% CrIs. We will present probabilities of any benefit/harm, clinically important benefit/harm and probabilities of effects smaller than pre-defined clinically minimally important differences for all outcomes analysed. Analyses will be adjusted for stratification variables and conducted using weakly informative priors supplemented by sensitivity analyses using sceptic priors. DISCUSSION This secondary, pre-planned Bayesian analysis will supplement the primary, conventional analysis and may help clinicians, researchers and policymakers interpret the results of the COVID STEROID 2 trial while avoiding arbitrarily dichotomised interpretations of the results. TRIAL REGISTRATION ClinicalTrials.gov: NCT04509973; EudraCT: 2020-003363-25.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Marie Warrer Munch
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial HospitalHomi Bhabha National InstituteMumbaiIndia
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Department of Critical CareApollo HospitalsChennaiIndia
- Chennai Critical Care ConsultantsChennaiIndia
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
| | - Maria Cronhjort
- Department of Clinical Science and EducationSödersjukhuset, Karolinska InstitutetStockholmSweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and EducationSödersjukhuset, Karolinska InstitutetStockholmSweden
| | - Stephan M. Jakob
- Department of Intensive Care MedicineInselspital, Bern University Hospital, University of BernSwitzerland
| | - Luca Cioccari
- Department of Intensive Care MedicineInselspital, Bern University Hospital, University of BernSwitzerland
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Gitte Kingo Vesterlund
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Tine Sylvest Meyhoff
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Marie Helleberg
- Department of Infectious Diseases, RigshospitaletUniversity of CopenhagenDenmark
| | - Morten Hylander Møller
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Thomas Benfield
- Center of Research and Disruption of Infectious Diseases, Department of Infectious DiseasesCopenhagen University Hospital – Amager and HvidovreDenmark
| | | | - Naomi Hammond
- The George Institute for Global HealthUniversity of New South WalesAustralia
| | - Sharon Micallef
- The George Institute for Global HealthUniversity of New South WalesAustralia
| | - Abhinav Bassi
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
| | - Oommen John
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
- Prasanna School of Public HealthManipal Academy of Higher EducationIndia
| | - Vivekanand Jha
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
- Prasanna School of Public HealthManipal Academy of Higher EducationIndia
- School of Public HealthImperial College LondonUnited Kingdom
| | | | | | - Vibeke Lind Jørgensen
- Department of Thoracic Anaesthesiology, RigshospitaletUniversity of CopenhagenDenmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, RigshospitaletUniversity of CopenhagenDenmark
| | - Morten H. Bestle
- Department of Anaesthesiology Intensive CareCopenhagen University HospitalNordsjællandDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive CareHerlev Hospital, University of CopenhagenDenmark
| | | | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
- Department of Anaesthesia and Intensive CareAalborg University HospitalDenmark
| | | | - Thomas Strøm
- Department of Anaesthesia and Critical Care MedicineOdense University HospitalOdense CDenmark
- Department of Anaesthesia and Critical Care MedicineHospital Sønderjylland, University Hospital of Southern DenmarkDenmark
| | - Anders Møller
- Department of Anaesthesia and Intensive CareNæstved‐Slagelse‐Ringsted HospitalSlagelseDenmark
| | - Mohd Saif Khan
- Department of Critical Care MedicineRajendra Institute of Medical SciencesRanchiIndia
| | | | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial HospitalHomi Bhabha National InstituteMumbaiIndia
| | | | | | - Farhad Kapadia
- Section of Critical Care, Department of MedicineHinduja HospitalMahimIndia
| | - Subhal Dixit
- Department of Critical Care MedicineSanjeevan HospitalPuneIndia
| | - Rajesh Chawla
- Department of Respiratory and Critical Care MedicineIndraprastha Apollo HospitalNew DelhiIndia
| | - Urvi Shukla
- Intensive Care Unit and Emergency ServicesSymbiosis University Hospital and Research CentrePuneIndia
| | - Pravin Amin
- Department of Critical Care MedicineBombay Hospital Institute of Medical SciencesMumbaiIndia
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Theis Lange
- Department of Public Health, Section of BiostatisticsUniversity of CopenhagenCopenhagenDenmark
| | - Anders Perner
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
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22
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The proportion and effect of corticosteroid therapy in patients with COVID-19 infection: A systematic review and meta-analysis. PLoS One 2021; 16:e0249481. [PMID: 33882090 PMCID: PMC8059814 DOI: 10.1371/journal.pone.0249481] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 03/19/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives Coronavirus disease 2019 (COVID-19) remains a global challenge. Corticosteroids constitute a group of anti-inflammatory and immunosuppressive drugs that are widely used in the treatment of COVID-19. Comprehensive reviews investigating the comparative proportion and efficacy of corticosteroid use are scarce. Therefore, we conducted a systematic review and meta-analysis of clinical trials to evaluate the proportion and efficacy of corticosteroid use for the treatment of COVID-19. Methods We conducted a comprehensive literature review and meta-analysis of research articles, including observational studies and clinical trials, by searching the PubMed, EMBASE, Cochrane Controlled Trials Registry, and China Academic Journal Network Publishing databases. Patients treated between December 1, 2019, and January 1, 2021, were included. The outcome measures were the proportion of patients treated with corticosteroids, viral clearance and mortality. The effect size with the associated 95% confidence interval is reported as the weighted mean difference for continuous outcomes and the odds ratio for dichotomous outcomes. Results Fifty-two trials involving 15710 patients were included. The meta-analysis demonstrated that the proportion of COVID-19 patients who received corticosteroids was significantly lower than that of patients who did not receive corticosteroids (35.19% vs. 64.49%). In addition, our meta-analysis demonstrated no significant difference in the proportions of severe and nonsevere cases treated with corticosteroids (27.91% vs. 20.91%). We also performed subgroup analyses stratified by whether patients stayed in the intensive care unit (ICU) and found that the proportion of patients who received corticosteroids was significantly higher among those who stayed in the ICU than among those who did not. The results of our meta-analysis indicate that corticosteroid treatment significantly delayed the viral clearance time. Finally, our meta-analysis demonstrated no significant difference in the use of corticosteroids for COVID-19 between patients who died and those who survived. This result indicates that mortality is not correlated with corticosteroid therapy. Conclusion The proportion of COVID-19 patients who received corticosteroids was significantly lower than that of patients who did not receive corticosteroids. Corticosteroid use in subjects with severe acute respiratory syndrome coronavirus 2 infections delayed viral clearance and did not convincingly improve survival; therefore, corticosteroids should be used with extreme caution in the treatment of COVID-19.
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23
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Pathak GA, Wendt FR, Goswami A, Angelis FD, Polimanti R. ACE2 Netlas: In-silico functional characterization and drug-gene interactions of ACE2 gene network to understand its potential involvement in COVID-19 susceptibility. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.10.27.20220665. [PMID: 33140059 PMCID: PMC7605570 DOI: 10.1101/2020.10.27.20220665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Angiotensin-converting enzyme-2 ( ACE2 ) receptor has been identified as the key adhesion molecule for the transmission of the SARS-CoV-2. However, there is no evidence that human genetic variation in ACE2 is singularly responsible for COVID-19 susceptibility. Therefore, we performed a multi-level characterization of genes that interact with ACE2 (ACE2-gene network) for their over-represented biological properties in the context of COVID-19. The phenome-wide association of 51 genes including ACE2 with 4,756 traits categorized into 26 phenotype categories, showed enrichment of immunological, respiratory, environmental, skeletal, dermatological, and metabolic domains (p<4e-4). Transcriptomic regulation of ACE2-gene network was enriched for tissue-specificity in kidney, small intestine, and colon (p<4.7e-4). Leveraging the drug-gene interaction database we identified 47 drugs, including dexamethasone and spironolactone, among others. Considering genetic variants within ± 10 kb of ACE2-network genes we characterized functional consequences (among others) using miRNA binding-site targets. MiRNAs affected by ACE2-network variants revealed statistical over-representation of inflammation, aging, diabetes, and heart conditions. With respect to variants mapped to the ACE2-network, we observed COVID-19 related associations in RORA, SLC12A6 and SLC6A19 genes. Overall, functional characterization of ACE2-gene network highlights several potential mechanisms in COVID-19 susceptibility. The data can also be accessed at https://gpwhiz.github.io/ACE2Netlas/.
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Affiliation(s)
- Gita A Pathak
- Yale School of Medicine, Department of Psychiatry, Division of Human Genetics, New Haven, CT Veteran Affairs Connecticut Healthcare System, West Haven, CT
| | - Frank R Wendt
- Yale School of Medicine, Department of Psychiatry, Division of Human Genetics, New Haven, CT Veteran Affairs Connecticut Healthcare System, West Haven, CT
| | - Aranyak Goswami
- Yale School of Medicine, Department of Psychiatry, Division of Human Genetics, New Haven, CT Veteran Affairs Connecticut Healthcare System, West Haven, CT
| | - Flavio De Angelis
- Yale School of Medicine, Department of Psychiatry, Division of Human Genetics, New Haven, CT Veteran Affairs Connecticut Healthcare System, West Haven, CT
| | - Renato Polimanti
- Yale School of Medicine, Department of Psychiatry, Division of Human Genetics, New Haven, CT Veteran Affairs Connecticut Healthcare System, West Haven, CT
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24
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Petersen MW, Meyhoff TS, Helleberg M, Kjær MN, Granholm A, Hjortsø CJS, Jensen TS, Møller MH, Hjortrup PB, Wetterslev M, Vesterlund GK, Russell L, Jørgensen VL, Tjelle K, Benfield T, Ulrik CS, Andreasen AS, Mohr T, Bestle MH, Poulsen LM, Hitz MF, Hildebrandt T, Knudsen LS, Møller A, Sølling CG, Brøchner AC, Rasmussen BS, Nielsen H, Christensen S, Strøm T, Cronhjort M, Wahlin RR, Jakob S, Cioccari L, Venkatesh B, Hammond N, Jha V, Myatra SN, Gluud C, Lange T, Perner A. Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia (COVID STEROID) trial-Protocol and statistical analysis plan. Acta Anaesthesiol Scand 2020; 64:1365-1375. [PMID: 32779728 PMCID: PMC7404666 DOI: 10.1111/aas.13673] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus-2 has caused a pandemic of coronavirus disease (COVID-19) with many patients developing hypoxic respiratory failure. Corticosteroids reduce the time on mechanical ventilation, length of stay in the intensive care unit and potentially also mortality in similar patient populations. However, corticosteroids have undesirable effects, including longer time to viral clearance. Clinical equipoise on the use of corticosteroids for COVID-19 exists. METHODS The COVID STEROID trial is an international, randomised, stratified, blinded clinical trial. We will allocate 1000 adult patients with COVID-19 receiving ≥10 L/min of oxygen or on mechanical ventilation to intravenous hydrocortisone 200 mg daily vs placebo (0.9% saline) for 7 days. The primary outcome is days alive without life support (ie mechanical ventilation, circulatory support, and renal replacement therapy) at day 28. Secondary outcomes are serious adverse reactions at day 14; days alive without life support at day 90; days alive and out of hospital at day 90; all-cause mortality at day 28, day 90, and 1 year; and health-related quality of life at 1 year. We will conduct the statistical analyses according to this protocol, including interim analyses for every 250 patients followed for 28 days. The primary outcome will be compared using the Kryger Jensen and Lange test in the intention to treat population and reported as differences in means and medians with 95% confidence intervals. DISCUSSION The COVID STEROID trial will provide important evidence to guide the use of corticosteroids in COVID-19 and severe hypoxia.
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