Corticosteroids as a treatment for COVID-19 (multiple reviews)
What is this? Some patients with COVID-19 may develop complications such as pneumonia or respiratory distress. Corticosteroids have anti-inflammatory and immunomodulatory properties which may make them suitable as a treatment for this.
Several systematic reviews have been done and are summarised here. These include rapid reviews of COVID-19 research and earlier reviews of the effects of corticosteroids for various respiratory problems. More details of these reviews, including citations and links to their full text, are available lower down this summary.
What was found:
At the time of these reviews, the evidence base for the effects of corticosteroids for COVID-19 was inconclusive; but there is some evidence that corticosteroids may improve patient outcomes.
The most recent of the reviews (Singh 2020) is the only one to include the large randomised RECOVERY trial, which was published as a pre-print in June 2020 and in a journal in July 2020 and found marked reductions in mortality for patients with COVID-19 who are ventilated or receiving supplementary oxygen therapy when treated corticosteroid compared with usual care, but no benefit in patients with mild COVID-19 infection.
At the time of the Ye 2020 review, the included studies suggested that corticosteroid use might reduce mortality from COVID-19 and acute respiratory distress syndrome (ARDS), and might reduce the duration of mechanical ventilation. They also identified that cautious individual risk assessment may be required and that there were no confirmed biomarkers to guide the use of corticosteroids for COVID-19.
At the time of the Lu 2020 and Yang 2020 reviews, it was noted that corticosteroid treatment may reduce the symptoms and clinical signs of COVID-19 in some patients (for example reduction in fever), but, in the studies included in these reviews, this benefit was outweighed by higher risks of mortality or other complications. Lu 2020 also noted that corticosteroid treatment is not recommended for use in children with COVID-19 infection.
Stern (2017) reported that corticosteroids might reduce mortality in severe pneumonia and reduce morbidity in adults with non-severe pneumonia.
Lewis (2019) reported that using corticosteroids for ARDS might reduce all-cause mortality within three months and increase the number of ventilator-free days.
Saunders-Hastings (2016) reported that corticosteroid treatment had no effect on acute lung injury (which may develop as a complication of COVID-19 infection).
What are the reviews:
Citation: Lewis SR, Pritchard MW, Thomas CM, et al. Pharmacological agents for adults with acute respiratory distress syndrome. Cochrane Database of Systematic Reviews 2019;(7):CD004477.
In this Cochrane review, the authors searched for randomized trials of drugs for adults with ARDS. They did not restrict by language of publication and searched for studies published from 2000 to 2018. They identified 48 eligible studies (6299 participants) of five principal types of agent: corticosteroids, surfactants, N-acetylcysteine, statins and beta-agonists.
Citation: Li H, Chen C, Hu F, et al. Impact of corticosteroid therapy on outcomes of persons with SARS-CoV-2, SARS-CoV, or MERS-CoV infection: a systematic review and meta-analysis. Leukemia 2020 Jun:34(6):1503-11.
In this rapid review, the authors searched for studies of corticosteroids for COVID-19, SARS and MERS. They restricted their searches to articles published in English and Chinese and searched on 20 March 2020. They included one randomized trial and 10 cohort studies; 4 of the included studies focused on COVID-19.
Citation: Lu S, Zhou Q, Huang L, et al. Effectiveness and safety of glucocorticoids to treat COVID-19: a rapid review and meta-analysis. Annals of Translational Medicine 2020 May;8(10):627.
In this rapid review, the authors searched for studies of steroids for children and adults with COVID-19, SARS and MERS. They restricted their search to articles published in English and Chinese and searched from 2003 to 31 March 2020. They included one randomized trial and 22 cohort studies, with a total of 13,815 patients; 5 included studies assessed corticosteroids for COVID-19.
Citation: Saunders-Hastings P, Reisman J, Krewski D. Assessing the state of knowledge regarding the effectiveness of interventions to contain pandemic influenza transmission: a systematic review and narrative synthesis. PLOS One 2016;11(12):e0168262.
In this systematic overview and narrative syntheses, the authors searched for systematic reviews and meta-analyses of interventions for containing pandemic influenza transmission. They did not restrict by date or language of publication and did their searches in July 2016. They included 17 reviews.
Citation: Singh AK, Majumdar S, Singh R, Misra A. Role of corticosteroid in the management of COVID-19: A systematic review and Clinician’s perspective. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2020;14(5):971-8.
In this rapid review, the authors searched for studies of corticosteroids for COVID-19 and ARDS secondary to other viral diseases. They completed their search on 17 June 2020 and included 5 studies (including the preliminary results of the RECOVERY trial).
Citation: Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database of Systematic Reviews 2017;(12):CD007720.
In this Cochrane review, the authors searched for randomized trials of corticosteroids for children and adults with pneumonia. They did their search in March 2017. They included 4 studies in children (310 participants) and 13 studies in adults (1954 participants).
Citation: Yang JW, Yang L, Luo RG, et al. Corticosteroid administration for viral pneumonia: COVID-19 and beyond. Clinical Microbiology and Infection. 2020 Jun 27;26(9):1171-7.
In this rapid review, the authors searched for studies of corticosteroids for influenza, SARS, MERS and COVID-19 pneumonia. They did not restrict their search by language of publication and searched up to 30 April 2020. They included 782 studies, of which 341 focused on corticosteroids and COVID-19. Almost all the included studies were observational studies.
Citation: Yang Z, Liu J, Zhou Y, et al. The effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis. Journal of Infection 2020 Jul;81(1):e13-20.
In this rapid review, the authors searched for studies of corticosteroids for coronavirus infections. They restricted their searches to studies published since January 2002, but did not restrict by type or language of publication, and did the search on 15 March 2020. They included 15 studies, covering SARS (11 studies), MERS (2) and COVID-19 (2).
Citation: Ye Z, Wang Y, Colunga-Lozano LE, et al. Efficacy and safety of corticosteroids in COVID-19 based on evidence for COVID-19, other coronavirus infections, influenza, community-acquired pneumonia and acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ 2020 Jul 6;192(27):E756-67.
In this rapid review, the authors searched for studies of corticosteroids for COVID-19, other respiratory infections and ARDS. They also updated systematic reviews on ARDS, influenza and community-acquired pneumonia (CAP). They completed their search at the end of April 2020. They included 10 cohort studies and one randomized trial; 6 included studies focused on COVID-19 (with one of these focusing on COVID-19 and ARDS). Their updated systematic reviews on ARDS included 7 randomized trials, influenza (31 studies) and CAP (13 randomized trials).
Other reviews relevant to this topic:
Citation: Hermans G, De Jonghe B, Bruyninckx F, et al. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database of Systematic Reviews 2014;(1):CD006832.
Citation: Lansbury L, Rodrigo C, Leonardi-Bee J, et al. Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Database of Systematic Reviews 2019;(2):CD010406.
Citation: Morra ME, Van Thanh L, Kamel MG, et al. Clinical outcomes of current medical approaches for Middle East respiratory syndrome: A systematic review and meta-analysis. Reviews in Medical Virology 2018;28:e1977.
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