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Martins PN, Lourenço MHT, Mota GPS, Cavalcanti AB, Peçanha Antonio AC, Diaz-Quijano FA. Composite endpoints in COVID-19 randomized controlled trials: a systematic review. Clin Trials 2024:17407745241276130. [PMID: 39390767 DOI: 10.1177/17407745241276130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
BACKGROUND/AIMS This study aimed to determine the prevalence of ordinal, binary, and numerical composite endpoints among coronavirus disease 2019 trials and the potential bias attributable to their use. METHODS We systematically reviewed the Cochrane COVID-19 Study Register to assess the prevalence, characteristics, and bias associated with using composite endpoints in coronavirus disease 2019 randomized clinical trials. We compared the effect measure (relative risk) of composite outcomes and that of its most critical component (i.e. death) by estimating the Bias Attributable to Composite Outcomes index [ln(relative risk for the composite outcome)/ln(relative risk for death)]. RESULTS Composite endpoints accounted for 152 out of 417 primary endpoints in coronavirus disease 2019 randomized trials, being more frequent among studies published in high-impact journals. Ordinal endpoints were the most common (54% of all composites), followed by binary or time-to-event (34%), numerical (11%), and hierarchical (1%). Composites predominated among trials enrolling patients with severe disease when compared to trials with a mild or moderate case mix (odds ratio = 1.72). Adaptations of the seven-point World Health Organization scale occurred in 40% of the ordinal primary endpoints, which frequently underwent dichotomization for the statistical analyses. Mortality accounted for a median of 24% (interquartile range: 6%-48%) of all events when included in the composite. The median point estimate of the Bias Attributable to Composite Outcomes index was 0.3 (interquartile range: -0.1 to 0.7), being significantly lower than 1 in 5 of 24 comparisons. DISCUSSION Composite endpoints were used in a significant proportion of coronavirus disease 2019 trials, especially those involving severely ill patients. This is likely due to the higher anticipated rates of competing events, such as death, in such studies. Ordinal composites were common but often not fully appreciated, reducing the potential gains in information and statistical efficiency. For studies with binary composites, death was the most frequent component, and, unexpectedly, composite outcome estimates were often closer to the null when compared to those for mortality death. Numerical composites were less common, and only two trials used hierarchical endpoints. These newer approaches may offer advantages over traditional binary and ordinal composites; however, their potential benefits warrant further scrutiny. CONCLUSION Composite endpoints accounted for more than a third of coronavirus disease 2019 trials' primary endpoints; their use was more common among studies that included patients with severe disease and their point effect estimates tended to underestimate those for mortality.
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Affiliation(s)
- Pedro Nascimento Martins
- Federal University of Juiz de Fora, Juiz de Fora, Brazil
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
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Wang S, Chen Z, Zhang X, Wu X, Wang Y, Zhang Q, Huang L, Cui X, Cai Y, Huang X, Xia J, Gu S, Li M, Zhan Q. Impact of corticosteroid doses on prognosis of severe and critical COVID-19 patients with Omicron variant infection: a propensity score matching study. Inflammopharmacology 2024; 32:3347-3356. [PMID: 39120772 PMCID: PMC11416397 DOI: 10.1007/s10787-024-01520-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/23/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND There is lack of research on corticosteroid use for severe and critical COVID-19 patients with Omicron variant infection. METHODS This multi-center retrospective cohort study involved 1167 patients from 59 ICUs across the mainland of China diagnosed with severe or critical SARS-CoV-2 Omicron variant infection between November 1, 2022, and February 11, 2023. Patients were segregated into two groups based on their corticosteroid treatment-usual dose (equivalent prednisone dose 30-50 mg/day) and higher dose (equivalent prednisone dose > 50 mg/day). The primary outcome was 28-day ICU mortality. Propensity score matching was used to compare outcomes between cohorts. RESULTS After propensity score matching, 520 patients in the usual dose corticosteroid group and 260 patients in the higher dose corticosteroid group were included in the analysis, respectively. The mortality was significantly higher in the higher dose corticosteroid group (67.3%, 175/260) compared to the usual dose group (56.0%, 291/520). Logistic regression showed that higher doses of corticosteroids were significantly associated with increased mortality at 28-day (OR = 1.62,95% CI 1.19-2.21, p = 0.002) and mortality in ICU stay (OR = 1.66,95% CI 1.21-2.28, p = 0.002). Different types of corticosteroids did not affect the effect. CONCLUSIONS The study suggests that higher-dose corticosteroids may lead to a poorer prognosis for severe and critical COVID-19 patients with Omicron variant infection in the ICU. Further research is needed to determine the appropriate corticosteroid dosage for these patients.
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Affiliation(s)
- Shiyao Wang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Ziying Chen
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Xinran Zhang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical research and Data management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaojing Wu
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Yuqiong Wang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Qi Zhang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Linna Huang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Xiaoyang Cui
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Ying Cai
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Xu Huang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Jingen Xia
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Sichao Gu
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Min Li
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China
| | - Qingyuan Zhan
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, #2 Yinghuayuan East Street, Chaoyang District, Beijing, 100029, China.
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Crescioli E, Nielsen FM, Bunzel AM, Eriksen ASB, Siegemund M, Poulsen LM, Andreasen AS, Bestle MH, Iversen SA, Brøchner AC, Grøfte T, Hildebrandt T, Laake JH, Kjær MBN, Lange T, Perner A, Klitgaard TL, Schjørring OL, Rasmussen BS. Long-term mortality and health-related quality of life with lower versus higher oxygenation targets in intensive care unit patients with COVID-19 and severe hypoxaemia. Intensive Care Med 2024; 50:1603-1613. [PMID: 39235624 PMCID: PMC11446942 DOI: 10.1007/s00134-024-07613-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 08/12/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE The aim of this study was to evaluate one-year outcomes of lower versus higher oxygenation targets in intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia. METHODS We conducted pre-planned analyses of one-year mortality and health-related quality of life (HRQoL) in the Handling Oxygenation Targets in COVID-19 trial. The trial randomised 726 ICU patients with COVID-19 and hypoxaemia to partial pressure of arterial oxygen targets of 8 kPa (60 mmHg) versus 12 kPa (90 mmHg) during ICU stay up to 90 days, including readmissions. HRQoL was assessed using EuroQol visual analogue scale (EQ-VAS) and 5-level 5-dimension questionnaire (EQ-5D-5L). Outcomes were analysed in the intention-to-treat population. Non-survivors were assigned the worst possible score (zero), and multiple imputation was applied for missing EQ-VAS values. RESULTS We obtained one-year vital status for 691/726 (95.2%) of patients and HRQoL data for 642/726 (88.4%). At one year, 117/348 (33.6%) of patients in the lower-oxygenation group had died compared to 134/343 (39.1%) in the higher-oxygenation group (adjusted risk ratio: 0.85; 98.6% confidence interval (CI) 0.66-1.09; p = 0.11). Median EQ-VAS was 50 (interquartile range, 0-80) versus 40 (0-75) (adjusted mean difference: 4.8; 98.6% CI - 2.2 to 11.9; p = 0.09) and EQ-5D-5L index values were 0.61 (0-0.81) in the lower-oxygenation group versus 0.43 (0-0.79) (p = 0.20) in the higher-oxygenation group, respectively. CONCLUSION Among adult ICU patients with COVID-19 and severe hypoxaemia, one-year mortality results were most compatible with benefit of the lower oxygenation target, which did not appear to result in more survivors with poor quality of life.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Marie Bunzel
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
| | - Anne Sofie Broberg Eriksen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
| | - Martin Siegemund
- Department of Intensive Care, Acute Medicine, Basel University Hospital, Basel, Switzerland
| | | | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Herlev, Copenhagen, Denmark
| | - Morten Heiberg Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Andi Iversen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | | | - Thorbjørn Grøfte
- Department of Anaesthesia and Intensive Care, Randers Hospital, Randers, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Jon Henrik Laake
- Department of Anaesthesia and Intensive Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Maj-Brit Nørregaard Kjær
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Sethi I, Shaikh A, Sethi M, Chohan HK, Younus S, Khan SA, Surani S. Dosage and utilization of dexamethasone in the management of COVID-19: A critical review. World J Virol 2024; 13:95709. [PMID: 39323444 PMCID: PMC11401006 DOI: 10.5501/wjv.v13.i3.95709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 06/19/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The severe respiratory manifestations observed in severe coronavirus disease 2019 (COVID-19) cases are often associated with an excessive inflammatory response. Dexamethasone, a synthetic glucocorticoid, exerts its anti-inflammatory effects by inhibiting the transcription of pro-inflammatory genes and suppressing the activity of various immune cells. This mechanism has implications for mitigating the cytokine storm observed in severe COVID-19 cases. Early on in the pandemic, the Recovery Collaborative working group showed a mortality benefit of using dexamethasone in decreasing mortality in patients with COVID-19 requiring respiratory support. However, the optimal dosage of corticosteroids remains debatable. Several studies that compare different doses of dexamethasone in COVID-19 exist, but the results are conflicting. AIM To review the latest evidence regarding dosage, safety, and efficacy of dexamethasone in severe COVID-19. METHODS We followed preferred reporting items for systematic reviews and meta-analysis guidelines. A detailed literature search was conducted across PubMed, Google Scholar, and Medline to include publications up to March 2024. Our keywords included "COVID-19" "SARS-CoV-2" "dexamethasone" "corticosteroid" "steroid" and "glucocorticoid"-along with their combinations. We employed the Cochrane Risk of Bias Tool and the Newcastle-Ottawa scale to evaluate the integrity and potential of bias in the included studies. A meta-analysis was conducted using a random-effects model, assessing pooled odds ratios and mean differences, with heterogeneity gauged by the I 2 statistic and the χ 2 tests. RESULTS No statistical differences were found in 28-day all-cause mortality [pooled odds ratio (OR) = 1.109, 95%CI: 0.918-1.340], 60-day all-cause mortality (OR = 0.873, 95%CI: 0.744-1.024; I 2 = 47.29%), mean length of hospital stay (mean difference = -0.08 days, 95%CI: -0.001 to 0.161) and adverse events (OR = 0.877, 95%CI: 0.707-1.087). CONCLUSION Differing doses of corticosteroids have no clinical implications on mortality, mean length of hospital stay, and adverse events in COVID-19 patients. Additional research is required in patients requiring invasive or non-invasive ventilation.
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Affiliation(s)
- Imran Sethi
- Department of Critical Care Medicine, Marion General Hospital, Marion, IN 46952, United States
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Karachi 74200, Sindh, Pakistan
| | - Musa Sethi
- Department of Medicine, Eman School, Fishers, IN 46038, United States
| | - Hira Khalid Chohan
- Department of Internal Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Sheraz Younus
- Department of Hospital Medicine, Franciscan Health, Indianapolis, IN 46237, United States
| | - Syed A Khan
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
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Jones TW, Hendrick T, Chase AM. Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer. Am J Health Syst Pharm 2024; 81:812-832. [PMID: 38742459 DOI: 10.1093/ajhp/zxae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect. SUMMARY The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research. CONCLUSION The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.
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Affiliation(s)
- Timothy W Jones
- Department of Pharmacy, Piedmont Eastside Medical Center, Snellville, GA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Tanner Hendrick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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Lee R, Cho SY, Lee DG, Nho D. High-Dose Corticosteroid Use in Severe to Critically Ill Patients With COVID-19: A Nationwide Population-Based Matched Cohort Study. J Korean Med Sci 2024; 39:e255. [PMID: 39228186 PMCID: PMC11372411 DOI: 10.3346/jkms.2024.39.e255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/09/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Systemic corticosteroids have become the standard of care for severe to critically ill patients with coronavirus disease 2019 (COVID-19). However, the real-world efficacy and safety outcomes associated with a higher dose of corticosteroids remain uncertain. METHODS We conducted a nationwide, population-based, matched cohort study of severe to critically ill adult patients with COVID-19 between January 2020 and June 2021 in Korea using the National Health Information Database. Patients using systemic corticosteroids were included and high-dose corticosteroid use was defined as a daily mean prescribed dose of more than 6 mg of dexamethasone. We then employed a proportional hazard regression model to identify prognostic factors for 28-day all-cause mortality and conducted a Fine and Gray regression model to assess risk factors for developing COVID-19-associated pulmonary aspergillosis (CAPA). RESULTS During the study period, 102,304 patients with COVID-19 were screened, 5,754 met the eligibility criteria, and 2,138 were successfully matched. The mean prescribed daily dose was 4.2 mg and 13.4 mg in the standard- and high-dose groups, respectively, and the mean duration of use was not different between the groups. High-dose corticosteroid use independently increased all-cause mortality at 28 days (adjusted hazard ratio [aHR], 1.48; 95% confidence interval [CI], 1.25-1.76) and 90 days (aHR, 1.63; CI, 1.44-1.85) after admission. Subgroup analysis revealed a statistically significant elevation in the risk of mortality among patients using low-flow or high-flow nasal cannulas, with aHRs of 1.41 and 1.46, respectively. No significant impact of high-dose steroids was observed, even in patients who underwent mechanical ventilation at 28 days (aHR, 1.17; CI, 0.79-1.72). As a safety outcome, high-dose corticosteroid use showed an association with the development of CAPA (aHR, 2.97; 95% CI, 0.94-9.43). CONCLUSION Among severe to critically ill patients with COVID-19, high-dose corticosteroid use was associated with increased 28-day all-cause mortality and showed a trend toward the development of CAPA.
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Affiliation(s)
- Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Dukhee Nho
- Division of Infectious Diseases, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Odhiambo JO, Shah J, Kunyiha N, Makasa C, Riunga F. Outcomes of different steroid dosing regimens in critical Covid-19 pneumonia at a Kenyan hospital: A retrospective cohort study. PLoS One 2024; 19:e0307265. [PMID: 39163391 PMCID: PMC11335146 DOI: 10.1371/journal.pone.0307265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 07/01/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND Among therapeutic options for severe and critical COVID- 19 infection, dexamethasone six milligrams once daily for ten days has demonstrated mortality benefit and is guideline recommended at this dose. In practice, variable doses of steroids have been used, especially in critical care settings. Our study aimed to determine the pattern of steroid dosing and outcomes in terms of critical care mortality, occurrence of dysglycaemias, and occurrence of superadded infections in patients with critical COVID-19. METHODS A retrospective cohort study was carried out on all eligible patients admitted to the Aga Khan University Hospital, Nairobi, with critical COVID-19 between 1st March 2020 and 31st December 2021. The intervention of interest was corticosteroids quantified as the average daily dose in milligrams of dexamethasone. A steroid dose of six milligrams once a day was compared to high dose steroid dosing, which was defined as any dose greater than this. The primary outcome measure was ICU mortality and secondary outcomes included occurrence of dysglycaemias, superadded infections and duration of critical care admission. RESULTS The study included 288 patients. The median age was 61.2 years (IQR: 49.7, 72.5), with 71.2% of patients being male. The most common comorbidities were diabetes mellitus (60.7%), hypertension (58%), and heart disease (12.2%). The average oxygen saturation and C-reactive protein at admission were 82% [IQR: 70.0-89.0]and 113.0 [IQR: 54.0-186.0], respectively. Fifty-eight percent of patients received a standard dose (6mg) of steroids. The mortality rate was higher in the high-dose group compared to the standard-dose group; however, the difference was not statistically significant (47.9% vs 43.7% p = 0.549). The two most common steroid associated adverse effects were uncomplicated hyperglycemia (62.2%) and superimposed bacterial pneumonia (20.1%). The high-dose group had a higher incidence of uncomplicated hyperglycemia compared to the standard-dose group (63.6% vs 61.1%). However, the incidence of diabetic ketoacidosis was lower in the high dose group (0.6% vs 6.6%). Oxygen saturation at admission was associated with survival where it was lower among non-survivor patients with critical COVID-19. CONCLUSION The study found that high-dose steroids in the treatment of critically ill patients with COVID-19 pneumonia did not confer any mortality benefit and were associated with an increased risk of dysglycemia and superimposed infections.
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Affiliation(s)
- John Otieno Odhiambo
- Healthcare Practitioner at the Department of Internal Medicine, Aga University, Nairobi, Kenya
| | - Jasmit Shah
- Statistician at the Department of Internal Medicine and Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Nancy Kunyiha
- Healthcare Practitioner at the Department of Internal Medicine, Aga University, Nairobi, Kenya
| | - Charles Makasa
- Healthcare Practitioner at the Department of Internal Medicine, Aga University, Nairobi, Kenya
| | - Felix Riunga
- Healthcare Practitioner at the Department of Internal Medicine, Aga University, Nairobi, Kenya
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Komaenthammasophon C, Pachinburavan M, Chokesuwattanaskul R. Heart rate variability and mortality in critically ill COVID-19 pneumonia patients. Heliyon 2024; 10:e34842. [PMID: 39157314 PMCID: PMC11328018 DOI: 10.1016/j.heliyon.2024.e34842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/10/2024] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Background Heart rate variability (HRV) has prognostic value for predicting mortality in both cardiovascular and sepsis patients. Decreased HRV has been associated with increased mortality and morbidity. However, the prognostic significance of HRV in critically ill patients COVID-19 pneumonia still remains unknown. The current study aimed to (1) evaluate prognostic utility of HRV parameters on outcomes in patients with severe COVID-19 pneumonia and (2) assess the correlation between HRV parameters and inflammatory markers. Methods Consecutive critically ill patients with COVID-19 pneumonia admitted to a tertiary referral intensive care unit from October 2021 to June 2022 in Bangkok, Thailand were enrolled. HRV parameters over the 24 h following intensive care unit admission were recorded using telemetry and analyzed using the Holter program (Philips Holter 2010 Plus/1810 Series). Receiver-operating characteristic (ROC) curve analysis was used to determine optimum threshold cutoffs of various HRV parameters. Formal comparisons of in-hospital mortality between patients with and without a decrease in HRV were performed using Cox regression after adjusting for potential confounders. Results A total of 65 patients were enrolled in the study. Patients were classified into two groups: survivors (n = 44, 68 %) and non-survivors (n = 21, 32 %). The standard deviation of normal-to-normal intervals (SDNN) was significantly lower in non-survivors than in survivors (70.30 vs. 105.95; p = 0.03). The SDNN predicted in-hospital mortality with an area under the ROC curve of 0.67 (95 % CI 0.55-0.79). At a cutoff of 70 ms, the SDNN showed a sensitivity and specificity of 0.48 and 0.86. The low SDNN group (<70 ms) demonstrated higher median ferritin, IL-6, and hs-C-reactive protein levels than did the normal SDNN group, although such differences did not reach statistical significance (1139.0 vs. 508.4; p = 0.137 and 91.2 vs. 64.4; p = 0.352, respectively). After adjusting for potential confounders in the multivariable model, the adjusted hazard ratio for in-hospital mortality in those with SDNN <70 ms was 3.70 (95 % CI 1.34-10.24). Conclusion A decrease in SDNN, a commonly used HRV parameter, was associated with mortality and inflammatory biomarkers in critically ill patients with COVID-19 pneumonia.
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Affiliation(s)
- Chalermchai Komaenthammasophon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
- Division of Cardiology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Monvasi Pachinburavan
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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9
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Kenny G, Saini G, Gaillard CM, Negi R, Alalwan D, Garcia Leon A, McCann K, Tinago W, Kelly C, Cotter AG, de Barra E, Horgan M, Yousif O, Gautier V, Landay A, McAuley D, Feeney ER, O'Kane C, Mallon PWG. Early inflammatory profiles predict maximal disease severity in COVID-19: An unsupervised cluster analysis. Heliyon 2024; 10:e34694. [PMID: 39144942 PMCID: PMC11320140 DOI: 10.1016/j.heliyon.2024.e34694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 07/14/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Background The inflammatory changes that underlie the heterogeneous presentations of COVID-19 remain incompletely understood. In this study we aimed to identify inflammatory profiles that precede the development of severe COVID-19, that could serve as targets for optimised delivery of immunomodulatory therapies and provide insights for the development of new therapies. Methods We included individuals sampled <10 days from COVID-19 symptom onset, recruited from both inpatient and outpatient settings. We measured 61 biomarkers in plasma, including markers of innate immune and T cell activation, coagulation, tissue repair and lung injury. We used principal component analysis and hierarchical clustering to derive biomarker clusters, and ordinal logistic regression to explore associations between cluster membership and maximal disease severity, adjusting for known risk factors for severe COVID-19. Results In 312 individuals, median (IQR) 7 (4-9) days from symptom onset, we found four clusters. Cluster 1 was characterised by low overall inflammation, cluster 2 was characterised by higher levels of growth factors and markers of endothelial activation (EGF, VEGF, PDGF, TGFα, PAI-1 and p-selectin). Cluster 3 and 4 both had higher overall inflammation. Cluster 4 had the highest levels of most markers including markers of innate immune activation (IL6, procalcitonin, CRP, TNFα), and coagulation (D-dimer, TPO), in contrast cluster 3 had the highest levels of alveolar epithelial injury markers (RAGE, ST2), but relative downregulation of growth factors and endothelial activation markers, suggesting a dysfunctional inflammatory pattern. In unadjusted and adjusted analysis, compared to cluster 1, cluster 3 had the highest odds of progressing to more severe disease (unadjusted OR (95%CI) 9.02 (4.53-17.96), adjusted OR (95%CI) 6.02 (2.70-13.39)). Conclusion Early inflammatory profiles predicted subsequent maximal disease severity independent of risk factors for severe COVID-19. A cluster with downregulation of growth factors and endothelial activation markers, and early evidence of alveolar epithelial injury, had the highest risk of severe COVID-19.
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Affiliation(s)
- Grace Kenny
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, St Vincent's University Hospital, Dublin, Ireland
| | - Gurvin Saini
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Colette Marie Gaillard
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Riya Negi
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Dana Alalwan
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Alejandro Garcia Leon
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Kathleen McCann
- Department of Infectious Diseases, St Vincent's University Hospital, Dublin, Ireland
| | - Willard Tinago
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Christine Kelly
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aoife G. Cotter
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eoghan de Barra
- Department of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mary Horgan
- Department of Infectious Diseases, Cork University Hospital, Wilton, Cork, Ireland
| | - Obada Yousif
- Department of Endocrinology, Wexford General Hospital, Wexford, Ireland
| | - Virginie Gautier
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Alan Landay
- Department of Internal Medicine, Rush University, Chicago, IL, USA
| | | | - Eoin R. Feeney
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, St Vincent's University Hospital, Dublin, Ireland
| | | | - Patrick WG. Mallon
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, St Vincent's University Hospital, Dublin, Ireland
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10
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Abogunrin S, Adelakun A, Akinola T, Bashir U, Fagbohungbe B, Mueller E, Neeser K, Ogunnubi O, Parekh K. Challenges of consolidating evidence collected during a pandemic and lessons for the future. Curr Med Res Opin 2024; 40:1311-1322. [PMID: 38975733 DOI: 10.1080/03007995.2024.2377676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE To illustrate the challenges encountered when gathering rapidly synthesized evidence in response to the coronavirus disease 2019 (COVID-19) pandemic. METHODS In this article, we describe the challenges encountered when we performed a systematic literature review (SLR) of randomized controlled trials (RCTs) on the efficacy and safety of treatments for severe COVID-19. The methods of the SLR are described in full, to show the context of our objectives. Then we use the results of the SLR to demonstrate the problems of producing synthesized evidence in this setting. RESULTS Various challenges were identified during this SLR. These were primarily a result of heterogeneity in the study methodology of eligible studies. Definitions of the patient populations and outcome measurements were highly variable and the majority of studies demonstrated a high risk of bias, preventing quantitative synthesis of the collated evidence. CONCLUSION Consolidating evidence from RCTs evaluating COVID-19 interventions was problematic. Guidance is needed for scenarios with high rapid output in primary research.
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Affiliation(s)
| | - Alex Adelakun
- Manchester University Foundation Trust, Manchester, UK
| | | | - Usman Bashir
- Community Medicine Department, Bayero University Kano, Kano, Nigeria
| | | | | | | | - Oluseun Ogunnubi
- Department of Psychiatry, College of Medicine of the University of Lagos, Lagos, Nigeria
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11
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Braik R, Germain Y, Flet T, Chaba A, Guinot PG, Garreau L, Bar S, Diouf M, Abou-Arab O, Mahjoub Y, Berna P, Dupont H. Intraoperative dexamethasone is associated with a lower risk of respiratory failure in thoracic surgery: Observational cohort study (SURTHODEX). Anaesth Crit Care Pain Med 2024; 43:101386. [PMID: 38710322 DOI: 10.1016/j.accpm.2024.101386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery. METHODS We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect. RESULTS We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02). CONCLUSIONS Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Rayan Braik
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France.
| | - Yohan Germain
- Poly clinique Saint Côme, Service d'anesthésie-réanimation, Compiègne, France
| | - Thomas Flet
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Piere-Grégoire Guinot
- Centre hospitalier universitaire de Dijon, Département d'anesthésie-réanimation, Dijon, France
| | - Leo Garreau
- Centre hospitalier universitaire de Bordeaux, Département d'anesthésie-réanimation, Bordeaux, France
| | - Stephane Bar
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
| | - Momar Diouf
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
| | - Osama Abou-Arab
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
| | - Yazine Mahjoub
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
| | - Pascal Berna
- Clinique Victor Pauchet, Service de chirurgie thoracique, Amiens France
| | - Hervé Dupont
- Centre hospitalier universitaire d'Amiens, Département d'anesthésie-réanimation, Amiens, France
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12
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Pirracchio R, Venkatesh B, Legrand M. Low-Dose Corticosteroids for Critically Ill Adults With Severe Pulmonary Infections: A Review. JAMA 2024; 332:318-328. [PMID: 38865154 DOI: 10.1001/jama.2024.6096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Importance Severe pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%. Observations Corticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections. Conclusions and Relevance Treatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.
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Affiliation(s)
- Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco
- Associate Editor, JAMA
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales Sydney, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco
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13
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Ye X, Li Y, Luo F, Xu Z, Kasimu K, Wang J, Xu P, Tan C, Yi H, Luo Y. Efficacy and safety of glucocorticoids in the treatment of COVID-19: a systematic review and meta-analysis of RCTs. Clin Exp Med 2024; 24:157. [PMID: 39003393 PMCID: PMC11246314 DOI: 10.1007/s10238-024-01405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/14/2024] [Indexed: 07/15/2024]
Abstract
In the realm of acute respiratory infections, coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a global public health challenge. The application of corticosteroids (CSs) in COVID-19 remains a contentious topic among researchers. Accordingly, our team performed a comprehensive meta-analysis of randomized controlled trials (RCTs) to meticulously evaluate the safety and efficacy of CSs in hospitalized COVID-19 patients. To explore efficacy of CSs in the treatment of COVID-19 patients, we meticulously screened RCTs across key databases, including PubMed, Web of Science, Embase, Cochrane Library, ClinicalTrials.gov, as well as China's CNKI and Wanfang Data. We focused on assessing the 28 days mortality rates. We evaluated the data heterogeneity using the Chi-square test and I2 values, setting significance at 0.1 and 50%. Data from 21 RCTs involving 5721 participants were analyzed. The analysis did not demonstrate a significant association between CSs intervention and the 28 days mortality risk in hospitalized COVID-19 patients (relative risk [RR] = 0.93; 95% confidence interval [95% CI]: 0.84-1.03; P = 0.15). However, subgroup analysis revealed a significant reduction in 28 days mortality among patients with moderate-to-severe COVID-19 (RR at 0.85; 95% CI: 0.76-0.95; P = 0.004). Specifically, short-term CS administration (≤ 3 days) was associated with a substantial improvement in clinical outcomes (RR = 0.24; 95% CI: 0.09-0.63; P = 0.004), as was longer-term use (≥ 8 days) (RR = 0.88; 95% CI: 0.77-0.99; P = 0.04). Additionally, in patients with moderate-to-severe COVID-19, the administration of dexamethasone increased the number of 28 days ventilator-free days (Mean Difference = 1.92; 95% CI: 0.44-3.40; P = 0.01). Methylprednisolone also demonstrated significant benefits in improving clinical outcomes (RR = 0.24; 95% CI: 0.09-0.63; P = 0.004). Our meta-analysis demonstrated that although there is no significant difference in 28 days mortality rates among hospitalized COVID-19 patients, the use of CSs may be beneficial in improving clinical outcomes in moderate or severe COVID-19 patients. There was no significant increase in the occurrence of adverse events associated with the use of CSs. Our meta-analysis provides evidence that while CSs may not be suitable for all COVID-19 patients, they could be effective and safe in severely ill COVID-19 patients. Consequently, it is recommended to administer CSs for personalized treatments in COVID-19 cases to improve the clinical outcomes while minimizing adverse events.
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Affiliation(s)
- Xiangrong Ye
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Ye Li
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Feng Luo
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Zhibin Xu
- Department of Organ Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kaidirina Kasimu
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Juan Wang
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Peihang Xu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chunjiang Tan
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Hui Yi
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Yifeng Luo
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
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14
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Haan BJ, Blackmon SN, Cobb AM, Cohen HE, DeVier MT, Perez MM, Winslow SF. Corticosteroids in critically ill patients: A narrative review. Pharmacotherapy 2024; 44:581-602. [PMID: 38872437 DOI: 10.1002/phar.2944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.
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Affiliation(s)
- Bradley J Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Samantha N Blackmon
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Alex M Cobb
- Department of Pharmacy, Ascension St. John Medical Center, Tulsa, Oklahoma, USA
| | - Heather E Cohen
- Department of Pharmacy, Ascension Illinois Metro Region, Chicago, Illinois, USA
| | - Margaret T DeVier
- Department of Pharmacy, Ascension Saint Thomas Hospital Midtown, Nashville, Tennessee, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Samuel F Winslow
- Department of Pharmacy, Ascension Providence Hospital, Southfield, Michigan, USA
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15
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Sinha S, Patnaik R, Behera S. Steroids in acute respiratory distress syndrome: A panacea or still a puzzle? World J Crit Care Med 2024; 13:91225. [PMID: 38855281 PMCID: PMC11155495 DOI: 10.5492/wjccm.v13.i2.91225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/28/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a unique entity marked by various etiologies and heterogenous pathophysiologies. There remain concerns regarding the efficacy of particular medications for each severity level apart from respiratory support. Among several pharmacotherapies which have been examined in the treatment of ARDS, corticosteroids, in particular, have demonstrated potential for improving the resolution of ARDS. Nevertheless, it is imperative to consider the potential adverse effects of hyperglycemia, susceptibility to hospital-acquired infections, and the development of intensive care unit acquired weakness when administering corticosteroids. Thus far, a multitude of trials spanning several decades have investigated the role of corticosteroids in ARDS. Further stringent trials are necessary to identify particular subgroups before implementing corticosteroids more widely in the treatment of ARDS. This review article provides a concise overview of the most recent evidence regarding the role and impact of corticosteroids in the management of ARDS.
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Affiliation(s)
- Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar 751005, Odisha, India
| | - Rohit Patnaik
- Department of Critical Care Medicine, Medeor 24x7 Hospital, Al Danah 40330, Abu Dhabi, United Arab Emirates
| | - Srikant Behera
- Department of Internal Medicine and Critical Care, All India Institute of Medical Sciences, Bhubaneswar 751019, Odisha, India
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16
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Angermair S, Hardenberg JH, Rubarth K, Balzer F, Akbari N, Menk M, Spies C, Eckardt KU, Poddubnyy D, Siegmund B, Schneider T, Treskatsch S. In-hospital survival of critically ill COVID-19 patients treated with glucocorticoids: a multicenter real-world data study. Sci Rep 2024; 14:12138. [PMID: 38802435 PMCID: PMC11130266 DOI: 10.1038/s41598-024-62302-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
The COVID-19 pandemic has posed a major challenge to healthcare systems globally. Millions of people have been infected, and millions of deaths have been reported worldwide. Glucocorticoids have attracted worldwide attention for their potential efficacy in the treatment of COVID-19. Various glucocorticoids with different dosages and treatment durations have been studied in patients with different severities, with a suitable dosage and treatment duration not yet defined. This study aimed to investigate whether in-hospital survival differs between critically ill patients treated with low-dose glucocorticoids, high-dose glucocorticoids or no glucocorticoids. All critically ill patients admitted to the intensive care unit of the Charité Hospital-Universitätsmedizin Berlin between February 2020 and December 2021 with COVID-19 pneumonia receiving supplemental oxygen were eligible to participate in this multicenter real-world data study. Patients were retrospectively assigned to one of three groups: the high corticosteroid dose (HighC) group (receiving 6 mg parenteral dexamethasone or an equivalent corticosteroid dosage for ten days), the low corticosteroid dose (LowC) group (receiving less than 6 mg parenteral dexamethasone or an equivalent corticosteroid dosage for ten days), or the no corticosteroid (NoC) group. Overall survival and risk effects were compared among groups within the total observation period, as well as at 35 days after the onset of COVID-19 symptoms. Adjusted multivariable Cox proportional hazard regression analysis was performed to compare the risk of death between the treatment groups. Out of 1561 critically ill COVID-19 patients, 1014 were included in the baseline analysis. In the survival study, 1009 patients were assigned to the NoC (n = 346), HighC (n = 552), or LowC group (n = 111). The baseline characteristics were balanced between groups, except for age, BMI, APACHE II score, SOFA and SAPS II. While the 35-day survival did not show any differences, a landmark analysis of the patients surviving beyond 35 days revealed differences between groups. The restricted mean survival time was 112 days in the LowC group [95% CI: 97 - 128], 133 days in the HighC group [95% CI: 124 - 141] and 144 days in the NoC group [95% CI: 121 - 167]. The multivariable-adjusted Cox proportional hazard analysis indicated that, regardless of age, sex, health status or invasive oxygenation, a low-dose treatment increased the hazard of death of critically ill COVID-19 patients by a factor of 2.09 ([95% CI: 0.99, 4.4], p = 0.05) and a high-dose corticosteroid treatment increased the risk by a factor of 1.07 ([95% CI: 0.53, 2.15], p = 0.85) compared to no treatment with glucocorticoids. The analysis reveals that corticosteroid treatment does not influence the survival of critically ill COVID-19 patients in the intensive care unit within 35 days. Our evaluations further suggest that regardless of ventilation status, the decision-making process for administering corticosteroid therapy should account for the individual severity of the illness.
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Affiliation(s)
- Stefan Angermair
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Berlin, Germany.
| | - Jan-Hendrik Hardenberg
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Nilufar Akbari
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Mario Menk
- Medizinische Fakultät Carl Gustav Carus, Dresden, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, Campus Virchow-Klinikum and Charité Campus Mitte, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Division of Gastroenterology, Infectious Diseases, Rheumatology, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, 10117, Berlin, Germany
| | - Britta Siegmund
- Division of Gastroenterology, Infectious Diseases, Rheumatology, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, 10117, Berlin, Germany
| | - Thomas Schneider
- Division of Gastroenterology, Infectious Diseases, Rheumatology, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, 10117, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Berlin, Germany
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17
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Chaudhuri D, Nei AM, Rochwerg B, Balk RA, Asehnoune K, Cadena R, Carcillo JA, Correa R, Drover K, Esper AM, Gershengorn HB, Hammond NE, Jayaprakash N, Menon K, Nazer L, Pitre T, Qasim ZA, Russell JA, Santos AP, Sarwal A, Spencer-Segal J, Tilouche N, Annane D, Pastores SM. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med 2024; 52:e219-e233. [PMID: 38240492 DOI: 10.1097/ccm.0000000000006172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
RATIONALE New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency. OBJECTIVES To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP. PANEL DESIGN The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting. METHODS After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework. RESULTS In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence. CONCLUSIONS The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.
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Affiliation(s)
- Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robert A Balk
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | - Karim Asehnoune
- Department of Anesthesiology, CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Rhonda Cadena
- Department of Internal Medicine, Wake Forest School of Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Ricardo Correa
- Department of Endocrinology, Diabetes and Metabolism, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | | | - Annette M Esper
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine; Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Naomi E Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Critical Care Program, The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Kusum Menon
- Division of Pediatric Critical Care, University of Ottawa and Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, University of Ottawa and Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Lama Nazer
- King Hussein Cancer Center Department of Pharmacy, Amman, Jordan
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Zaffer A Qasim
- Department of Emergency Medicine and Critical Care Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - James A Russell
- Division of Critical Care, Department of Medicine, Centre for Heart Lung Innovation St. Paul's Hospital University of British Columbia, Vancouver, BC, Canada
| | - Ariel P Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Aarti Sarwal
- Department of Neurology [Neurocritical Care], Atrium Wake Forest School of Medicine, Winston Salem, NC
| | - Joanna Spencer-Segal
- Department of Internal Medicine and Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - Nejla Tilouche
- Intensive Care Unit, Service de Réanimation Polyvalente, Hôpital de Gonesse, Gonesse, France
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France
- School of Medicine Simone Veil, University of Versailles Saint Quentin, University Paris-Saclay, Versaillles, France
- IHU Prometheus Fédération Hospitalo-Universitaire SEPSIS, University Paris-Saclay, INSERM, Garches, France
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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18
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Lazar A. Recent Data about the Use of Corticosteroids in Sepsis-Review of Recent Literature. Biomedicines 2024; 12:984. [PMID: 38790946 PMCID: PMC11118609 DOI: 10.3390/biomedicines12050984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
Sepsis, characterized by life-threatening organ dysfunction due to a maladaptive host response to infection, and its more severe form, septic shock, pose significant global health challenges. The incidence of these conditions is increasing, highlighting the need for effective treatment strategies. This review explores the complex pathophysiology of sepsis, emphasizing the role of the endothelium and the therapeutic potential of corticosteroids. The endothelial glycocalyx, critical in maintaining vascular integrity, is compromised in sepsis, leading to increased vascular permeability and organ dysfunction. Corticosteroids have been used for over fifty years to treat severe infections, despite ongoing debate about their efficacy. Their immunosuppressive effects and the risk of exacerbating infections are significant concerns. The rationale for corticosteroid use in sepsis is based on their ability to modulate the immune response, promote cardiovascular stability, and potentially facilitate organ restoration. However, the evidence is mixed, with some studies suggesting benefits in terms of microcirculation and shock reversal, while others report no significant impact on mortality or organ dysfunction. The Surviving Sepsis Campaign provides cautious recommendations for their use. Emerging research highlights the importance of genomic and transcriptomic analyses in identifying patient subgroups that may benefit from corticosteroid therapy, suggesting a move toward personalized medicine in sepsis management. Despite potential benefits, the use of corticosteroids in sepsis requires careful consideration of individual patient risk profiles, and further research is needed to optimize their use and integrate genomic insights into clinical practice. This review underscores the complexity of sepsis treatment and the ongoing need for evidence-based approaches to improve patient outcomes.
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Affiliation(s)
- Alexandra Lazar
- Anesthesiology and Intensive Care Department, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Tirgu Mures, 540142 Targu Mures, Romania
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19
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Bolscher M, Koster SCE, Koopmans M, Haitsma Mulier JLG, Derde LPG, Juffermans NP. Anti-inflammatory therapies are associated with delayed onset of anemia and reduction in transfusion requirements in critically ill patients: results from two studies. Crit Care 2024; 28:114. [PMID: 38594746 PMCID: PMC11003051 DOI: 10.1186/s13054-024-04898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Anemia is a hallmark of critical illness, which is largely inflammatory driven. We hypothesized that the use of anti-inflammatory agents limits the development of anemia and reduces the need for red blood cell (RBC) transfusions in patients with a hyper-inflammatory condition due to COVID-19. METHODS An observational cohort (n = 772) and a validation cohort (a subset of REMAP-CAP, n = 119) of critically ill patients with hypoxemic respiratory failure due to COVID-19 were analyzed, who either received no treatment, received steroids or received steroids plus IL-6 blocking agents. The trajectory of hemoglobin (Hb) decline and the need for RBC transfusions were compared using descriptive statistics as well as multivariate modeling. RESULTS In both cohorts, Hb level was higher in the treated groups compared to the untreated group at all time points. In the observational cohort, incidence and number of transfused patients were lower in the group receiving the combination treatment compared to the untreated groups. In a multivariate analysis controlling for baseline Hb imbalance and mechanical ventilation, receipt of steroids remained associated with a slower decline in Hb level and the combination treatment remained associated with a slower decline of Hb and with less transfusions. Results remained the same in the validation cohort. CONCLUSION Immunomodulatory treatment was associated with a slower decline in Hb level in critically ill patients with COVID-19 and with less transfusion. Findings point toward inflammation as an important cause for the occurrence of anemia in the critically ill.
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Affiliation(s)
- Madelief Bolscher
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Matty Koopmans
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Lennie P G Derde
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
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20
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Granholm A, Lange T, Harhay MO, Jensen AKG, Perner A, Møller MH, Kaas-Hansen BS. Effects of duration of follow-up and lag in data collection on the performance of adaptive clinical trials. Pharm Stat 2024; 23:138-150. [PMID: 37837271 PMCID: PMC10935606 DOI: 10.1002/pst.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/07/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023]
Abstract
Different combined outcome-data lags (follow-up durations plus data-collection lags) may affect the performance of adaptive clinical trial designs. We assessed the influence of different outcome-data lags (0-105 days) on the performance of various multi-stage, adaptive trial designs (2/4 arms, with/without a common control, fixed/response-adaptive randomisation) with undesirable binary outcomes according to different inclusion rates (3.33/6.67/10 patients/day) under scenarios with no, small, and large differences. Simulations were conducted under a Bayesian framework, with constant stopping thresholds for superiority/inferiority calibrated to keep type-1 error rates at approximately 5%. We assessed multiple performance metrics, including mean sample sizes, event counts/probabilities, probabilities of conclusiveness, root mean squared errors (RMSEs) of the estimated effect in the selected arms, and RMSEs between the analyses at the time of stopping and the final analyses including data from all randomised patients. Performance metrics generally deteriorated when the proportions of randomised patients with available data were smaller due to longer outcome-data lags or faster inclusion, that is, mean sample sizes, event counts/probabilities, and RMSEs were larger, while the probabilities of conclusiveness were lower. Performance metric impairments with outcome-data lags ≤45 days were relatively smaller compared to those occurring with ≥60 days of lag. For most metrics, the effects of different outcome-data lags and lower proportions of randomised patients with available data were larger than those of different design choices, for example, the use of fixed versus response-adaptive randomisation. Increased outcome-data lag substantially affected the performance of adaptive trial designs. Trialists should consider the effects of outcome-data lags when planning adaptive trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Michael O. Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative
and Advanced Illness Research) Center, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics,
Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
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21
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Kovacevic P, Malic J, Kovacevic T, Dragic S, Zlojutro B, Jandric M, Momcicevic D, Cancarevic-Djajic B, Skrbic R, Rizwan MZ. Comparative Efficacy of High-Dose Dexamethasone Versus Methylprednisolone in Coronavirus Disease 2019 (COVID-19)-Associated Acute Respiratory Distress Syndrome. Cureus 2024; 16:e55725. [PMID: 38586644 PMCID: PMC10998658 DOI: 10.7759/cureus.55725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
OBJECTIVE This retrospective (matched paired) clinical trial aimed to compare the efficacy of dexamethasone vs. methylprednisolone at equipotent (high) doses in patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS). METHODS A total of 347 patients with moderate and severe COVID-19-associated ARDS were administered either a high (equipotent) dose of dexamethasone (32 mg) or methylprednisolone (180 mg) for a duration of up to 10 days. All participants received the standard of care for critically ill COVID-19 patients. RESULTS The primary outcomes included length of stay in the ICU, ICU mortality, and discharge from the hospital. Based on the obtained results, a tendency towards more favorable clinical outcomes concerning the length of stay in the ICU (in the group of patients treated with non-invasive mechanical ventilation (NIV), p<0.05), ICU mortality, and discharge from the hospital (in the group of patients who were intubated, p<0.05) in patients receiving the high dose of dexamethasone compared to those receiving methylprednisolone was observed. CONCLUSION It appears that severe cases of COVID-19, especially intubated ones, treated with high doses of dexamethasone have a more favorable clinical outcome than the use of equipotent doses of methylprednisolone. However, larger multicenter studies are needed to validate our observations.
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Affiliation(s)
- Pedja Kovacevic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Jovana Malic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Tijana Kovacevic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Sasa Dragic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Biljana Zlojutro
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Milka Jandric
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Danica Momcicevic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Branka Cancarevic-Djajic
- Critical Care Medicine, Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
| | - Ranko Skrbic
- Hospital-Based Medicine, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - M Zeeshan Rizwan
- Critical Care Medicine, Mayo Clinic Alix School of Medicine, Rochester, USA
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22
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Munch MW, Granholm A, Maláska J, Stašek J, Rodriguez PO, Pitre T, Wilson R, Savović J, Rochwerg B, Svobodnik A, Kratochvíl M, Taboada M, Jha V, Vijayaraghavan BKT, Myatra SN, Venkatesh B, Perner A, Møller MH. Dexamethasone doses in patients with COVID-19 and hypoxia: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2024; 68:146-166. [PMID: 37881881 DOI: 10.1111/aas.14346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/08/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The optimal dose of dexamethasone for severe/critical COVID-19 is uncertain. We compared higher versus standard doses of dexamethasone in adults with COVID-19 and hypoxia. METHODS We searched PubMed and trial registers until 23 June 2023 for randomised clinical trials comparing higher (>6 mg) versus standard doses (6 mg) of dexamethasone in adults with COVID-19 and hypoxia. The primary outcome was mortality at 1 month. Secondary outcomes were mortality closest to 90 days; days alive without life support; and the occurrence of serious adverse events/reactions (SAEs/SARs) closest to 1 month. We assessed the risk of bias using the Cochrane RoB2 tool, risk of random errors using trial sequential analysis, and certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We included eight trials (2478 participants), of which four (1293 participants) had low risk of bias. Higher doses of dexamethasone probably resulted in little to no difference in mortality at 1 month (relative risk [RR] 0.97, 95% CI: 0.79-1.19), mortality closest to Day 90 (RR 1.01, 95% CI: 0.86-1.20), and SAEs/SARs (RR 1.00, 95% CI: 0.97-1.02). Higher doses of dexamethasone probably increased the number of days alive without invasive mechanical ventilation and circulatory support but had no effect on days alive without renal replacement therapy. CONCLUSIONS Based on low to moderate certainty evidence, higher versus standard doses of dexamethasone probably result in little to no difference in mortality, SAEs/SARs, and days alive without renal replacement therapy, but probably increase the number of days alive without invasive mechanical ventilation and circulatory support.
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Affiliation(s)
- Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jan Maláska
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, Brno, Czech Republic
| | - Jan Stašek
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pablo O Rodriguez
- Pulmonary and Critical Care Medicine, Instituto Universitario CEMIC (Centro de Educación Médica e Investigación Clínica), Buenos Aires, Argentina
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Wilson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adam Svobodnik
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milan Kratochvíl
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Manuel Taboada
- Department of Anaesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Wesley Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Papic I, Bistrovic P, Keres T, Ortner Hadziabdic M, Lucijanic M. Patterns of corticosteroid use among remdesivir and matched patients and associated clinical outcomes in hospitalized COVID-19 patients. Expert Opin Pharmacother 2024; 25:215-222. [PMID: 38362773 DOI: 10.1080/14656566.2024.2320255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/14/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION We aimed to investigate patterns of corticosteroid use and their relationship with remdesivir use and clinical outcomes in a large real-life cohort of COVID-19 patients treated in a tertiary-level institution. METHODS We retrospectively analyzed a total of 1558 severe and critical COVID-19 patients, including 779 patients treated with remdesivir and 779 matched control patients. RESULTS A total of 167 (10.7%) patients received none, 710 (45.6%) low, 539 (34.6%) high, and 142 (9.1%) very high corticosteroid doses. Patients treated with remdesivir had significantly longer exposure to corticosteroids, received higher average and maximal daily doses, and cumulative corticosteroid doses. In the multivariate analysis remdesivir use, lower cumulative comorbidity burden, higher severity of COVID-19 symptoms, and mechanical ventilation were recognized as mutually independent predictors of the use of higher corticosteroid doses. Higher corticosteroid doses were associated with significantly increased mortality.Among non-remdesivir treated patients, there was a U-shaped relationship between maximal daily corticosteroid dose and mortality. Among remdesivir treated patients gradual increase in mortality with increasing corticosteroid doses was observed. CONCLUSION Patterns of corticosteroid use differ regarding the use of remdesivir and may moderate its association with survival among severe and critical COVID-19 patients.
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Affiliation(s)
- Ivan Papic
- Pharmacy Department, University Hospital Dubrava, Zagreb, Croatia
| | - Petra Bistrovic
- Cardiology Department, University Hospital Dubrava, Zagreb, Croatia
| | - Tatjana Keres
- Intensive Care department, University Hospital Dubrava, Zagreb, Croatia
| | - Maja Ortner Hadziabdic
- Centre for Applied Pharmacy, Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Marko Lucijanic
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
- Internal Medicine Department, School of Medicine, University of Zagreb, Zagreb, Croatia
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24
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Lu Y, Wang C, Wang Y, Chen Y, Zhao L, Li Y. Case report: Enhancing prognosis in severe COVID-19 through human herpes virus coinfection treatment strategies. Front Cell Infect Microbiol 2024; 13:1320933. [PMID: 38268789 PMCID: PMC10806028 DOI: 10.3389/fcimb.2023.1320933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
Background In the context of increasing reports of co-infection with coronavirus disease 2019 (COVID-19), particularly with human herpes viruses (HHVs), it is important to consider the appropriate treatment options for HHVs that have been reactivated by COVID-19. Case presentation This study presents two cases of severe COVID-19 with HHV co-infection. The first case involved a critically ill patient with COVID-19 co-infected with herpes simplex virus type 1, confirmed using metagenomic next-generation sequencing, and another patient with severe COVID-19 experiencing Epstein-Barr virus (EBV) reactivation, as evidenced by elevated EBV-DNA levels in the serum. Treatment included high-dose glucocorticoids and sivelestat sodium, with notable improvements observed after initiating ganciclovir anti-herpesvirus therapy. Conclusion This study underscores the significance of recognizing HHV co-infections in severe COVID-19 cases and highlights the potential of combining anti-HHV treatment, increased glucocorticoid dosages, and anti-cytokine storm therapy to enhance prognosis.
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Affiliation(s)
| | | | | | | | | | - Yu Li
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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25
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Tirupakuzhi Vijayaraghavan BK, Granholm A, Myatra SN, Jha V, Hammond N, Micallef S, Munch MW, Kjær MBN, Møller MH, Lange T, Perner A, Venkatesh B. Heterogeneity of treatment effect of higher dose dexamethasone by geographic region (Europe vs. India) in patients with COVID-19 and severe hypoxemia - a post hoc evaluation of the COVID STEROID 2 trial. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 20:100293. [PMID: 38234702 PMCID: PMC10794101 DOI: 10.1016/j.lansea.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/25/2023] [Indexed: 01/19/2024]
Abstract
Background In the COVID-STEROID 2 trial there was suggestion of heterogeneity of treatment effects (HTE) between patients enrolled from Europe vs. India on the primary outcome. Whether there was HTE for the remaining patient-centred outcomes is unclear. Methods In this post hoc analysis of the COVID-STEROID 2 trial, which compared 12 mg vs. 6 mg dexamethasone in adults with COVID-19 and severe hypoxemia, we evaluated HTE by geographical region (Europe vs. India) for secondary outcomes with analyses adjusted for stratification variables. Results are presented as risk differences (RDs) or mean differences (MDs) with 99% confidence intervals (CIs) and P-values from interaction tests. Findings There were differences in mortality at day 28 (RD for Europe -8.3% (99% CI: -17.7 to 1.0) vs. India 0.1% (99% CI: -10.0 to 10.0)), mortality at day 90 (RD for Europe -7.4% (99% CI: -17.1 to 2.0) vs. India -1.4% (99% CI: -12.8 to 9.8)), mortality at day 180 (RD for Europe -6.7% (99% CI: -16.4 to 2.9) vs. India -1.0% (99% CI: -12.3 to 10.3)), and number of days alive without life support at day 90 (MD for Europe 6.1 days (99% CI: -1.3 to 13.4) vs. India 1.7 days (99% CI: -8.4 to 11.8)). For serious adverse reactions, the direction was reversed (RD for Europe -1.0% (99% CI: -7.1 to 5.2) vs. India -5.3% (99% CI: -16.2 to 5.0). Interpretation Our analysis suggests higher dose dexamethasone may have less beneficial effects for patients in India as compared with those in Europe; however, the evidence is weak, and this could represent a chance finding. Funding None for this analysis. The COVID STEROID 2 trial was funded by The Novo Nordisk Foundation and supported by Rigshospitalet's Research Council.
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Affiliation(s)
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Sheila N. Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- School of Public Health, Imperial College London, United Kingdom
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sharon Micallef
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Maj-Brit N. Kjær
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | | | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
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26
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Kale-Pradhan PB, Pacitto R, Giuliano CA, Johnson LB. Evaluation of High-dose versus Standard-dose of Dexamethasone on Mortality among the Mechanically Ventilated COVID-19 Patients. Curr Drug Saf 2024; 19:350-355. [PMID: 37592771 DOI: 10.2174/1574886318666230817102043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION Anti-inflammatory agents like dexamethasone (DEX) are a mainstay of treatment for COVID-19. Despite randomized trials demonstrating that a 6 mg daily dose of DEX improved patient outcomes in hospitalized COVID-19 patients receiving oxygen, clinicians often prescribe higher doses of corticosteroids without evidence to support this practice. The purpose of this study was to compare outcomes of ventilated COVID-19 patients who received standard dose (SD) versus high dose (HD) DEX. METHODS This was a multi-site, retrospective, observational study on ventilated COVID-19- positive patients who received DEX for at least three days between June 1, 2020, and January 31, 2022. The primary outcome of this study was the association between mortality and SD (<6 mg daily) versus HD (>10 mg daily) DEX in ventilated COVID-19 patients. Secondary outcomes included average blood glucose (BG), number of BG readings above 200, incidence of bacterial nosocomial infection, ventilator-free days, length of stay (LOS), and ICU LOS. RESULTS Of the 212 included patients, 53 (25%) received SD DEX, and 159 (75%) received HD DEX. There was no significant effect of DEX dose on mortality, number of BG readings >200, incidence of nosocomial infections, LOS, or ventilator-free days (p >0.05). After controlling for confounding factors, no difference in mortality persisted (OR 1.34 95% CI 0.62- 2.90). Average daily BG and ICU LOS were significantly greater in the HD group compared to the SD group (p = 0.003, p = 0.019, respectively). CONCLUSION There was no association between HD DEX and mortality among ventilated COVID- 19 patients compared to SD DEX. Moreover, HD DEX is associated with detrimental effects such as prolonged ICU LOS and higher average daily BG. This study supports the use of SD DEX in ventilated COVID-19 patients.
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Affiliation(s)
- Pramodini B Kale-Pradhan
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, 48202, USA
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | | | - Christopher A Giuliano
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, 48202, USA
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Leonard B Johnson
- Division of Infectious Diseases, Ascension St. John Hospital, Detroit, MI, 48236, USA
- College of Medicine, Wayne State University, Detroit, MI, 48202, USA
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Grant JM, Lam J, Goyal SV, Lother S, Kassim SS, Lee SB, Chan J, Girouard G, Barrett L, Takaya S, Piszczek J, Vinh DC, Findlater AR, Saxinger L. AMMI Canada Practice Point: Updated recommendations for treatment of adults with symptomatic COVID-19 in 2023-2024. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2024; 8:245-252. [PMID: 38250615 PMCID: PMC10797770 DOI: 10.3138/jammi-2023-12-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Jennifer M Grant
- Divisions of Medical Microbiology and Infectious Diseases, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Lam
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
| | - Sohal V Goyal
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvain Lother
- Sections of Infectious Diseases and Critical Care, University of Manitoba, Manitoba, Canada
| | - Sameer S Kassim
- Department of Family Medicine, University of Manitoba, Manitoba, Canada
| | - Stephen B Lee
- Division of Infectious Diseases, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Justin Chan
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, USA
| | - Gabriel Girouard
- Centre hospitalier universitaire Dr-Georges-L.-Dumont Vitalité Health Network, Moncton, New Brunswick, Canada
| | - Lisa Barrett
- Infectious Diseases NSHA, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Satchan Takaya
- Division of Infectious Diseases, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jolanta Piszczek
- Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine; Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Aidan R Findlater
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lynora Saxinger
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
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Kaas-Hansen BS, Kjaer MBN, Møller MH, Jensen AKG, Larsen ME, Cuthbertson BH, Perner A, Granholm A. Health-related quality of life trajectories in critical illness: Protocol for a Monte Carlo simulation study. Acta Anaesthesiol Scand 2024; 68:122-129. [PMID: 37650374 DOI: 10.1111/aas.14324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is a patient-centred outcome increasingly used as a secondary outcome in critical care research. It may cover several important dimensions of clinical status in intensive care unit (ICU) patients that arguably elude other more easily quantified outcomes such as mortality. Poor associations with harder outcomes, conflicting data on HRQoL in critically ill compared to the background population, and paradoxical effects on HRQoL and mortality complicate the current operationalisation in critical care trials. This protocol outlines a simulation study that will gauge if the areas under the HRQoL trajectories could be a viable alternative. METHODS We will gauge the behaviour of the proposed HRQoL operationalisation through Monte Carlo simulations, under clinical scenarios that reflect a broad critical care population eligible for inclusion in a large pragmatic trial. We will simulate 15,360 clinical scenarios based on a full factorial design with the following seven simulation parameters: number of patients per arm, relative mortality reduction in the interventional arm, acceleration of HRQoL improvement in the interventional arm, the relative improvement in final HRQoL in the interventional arm, dampening effect of mortality on HRQoL values at discharge from the ICU, proportion of so-called mortality benefiters in the interventional arm and mortality trajectory shape. For each clinical scenario, we will simulate 100,000 two-arm trials with 1:1 randomisation. HRQoL will be sampled fortnightly after ICU discharge. Outcomes will include HRQoL in survivors and all patients at the end of follow-up; mean areas under the HRQoL trajectories in both arms; and mean difference between areas under the HRQoL trajectories and single-sampled HRQoLs at the end of follow-up. DISCUSSION In the outlined simulation study, we aim to assess whether the area under the HRQoL trajectory curve could be a candidate for reconciling the seemingly paradoxical effects on improved mortality and reduced HRQoL while remaining sensitive to early or accelerated improvement in patient outcomes. The resultant insights will inform subsequent methodological work on prudent collection and statistical analysis of such data from real critically ill patients.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mia Esta Larsen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Brian H Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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29
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Conroy GM, Bauer SR, Pallotta AM, Duggal A, Wang L, Sacha GL. Baricitinib versus tocilizumab in critically ill COVID-19 patients: A retrospective cohort study. Pharmacotherapy 2024; 44:28-38. [PMID: 37593883 PMCID: PMC10961678 DOI: 10.1002/phar.2867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The immunomodulators tocilizumab and baricitinib improve outcomes in severely ill patients with coronavirus disease 2019 (COVID-19); however, comparative analyses of clinical outcomes related to these agents are lacking. A tocilizumab national shortage shifted treatment to baricitinib in critically ill patients, allowing for an outcome comparison in a similar population. The purpose of this study is to compare clinical outcomes in critically ill COVID-19 patients who received tocilizumab and those who received baricitinib. DESIGN Retrospective, observational cohort study using generalized estimating equation models, accounting for clustering by hospital and known confounders, to estimate the proportional odds of the ordinal World Health Organization Clinical Progression Scale (WHO-CPS) score at day 14, the primary outcome. Secondary outcomes included WHO-CPS score at day 7. SETTING Multiple hospitals within the Cleveland Clinic Health System. PATIENTS Adult patients admitted for COVID-19 between January 2021 and November 2021. INTERVENTIONS Receipt of tocilizumab, before its shortage, or baricitinib, during shortage. MEASUREMENTS AND MAIN RESULTS In total, 507 patients were included; 217 received tocilizumab and 290 received baricitinib. Over 96% of patients required ICU admission and 98% received concomitant dexamethasone. Tocilizumab recipients had higher (worse) baseline WHO-CPS scores. After adjustment, tocilizumab use was associated with higher odds of a worse day 14 WHO-CPS score compared with baricitinib (adjusted odds ratio [OR] 1.65 [95% confidence interval (CI) 1.10-2.48]). Similarly, after adjustment, tocilizumab use was associated with higher odds of a worse day 7 WHO-CPS score (adjusted OR 1.65 [95% CI 1.22-2.24]). CONCLUSIONS Baricitinib use was associated with better WHO-CPS scores at day 14 and day 7 compared with tocilizumab in a cohort of critically ill patients with COVID-19. The odds of having a one unit increase in WHO-CPS score at day 14 was 71% higher with tocilizumab than baricitinib. No difference in mortality or adverse effects was noted.
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Affiliation(s)
| | - Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | | | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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30
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Zhou FW, Liu C, Li DZ, Zhang Y, Zhou FC. Efficacy and safety of corticosteroid therapy in patients with cardiac arrest: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 75:111-118. [PMID: 37939521 DOI: 10.1016/j.ajem.2023.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 10/05/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The clinical benefits of steroid therapy during cardiac arrest (CA) are unclear. Several recent clinical trials have shown that administering corticosteroid therapy during CA may improve patient outcomes. The purpose of the present study was to determine whether providing corticosteroids improves outcomes for patients following CA. METHODS We searched the PubMed, Embase, Cochrane Library, Web of Science and CNKI databases for randomized controlled trials comparing corticosteroid therapy to placebo during CA. RESULTS Eleven relevant studies involving a total of 2273 patients were included in the meta-analysis. The statistical analysis showed that corticosteroid treatment during CA was significantly associated with an increased rate of sustained return of spontaneous circulation (ROSC) (OR: 2.05, 95% CI: 1.24 to 3.37, P < 0.01). Corticosteroid treatment during CA did not show a significant benefit in favorable neurological outcomes (OR: 1.13, 95% CI: 0.81 to 1.58, P = 0.49) or overall survival rate at hospital discharge (OR: 1.29, 95% CI: 0.74 to 2.26, P = 0.38). However, in the subgroup analysis, we found that patients had a significantly increased survival rate and ROSC if the dose of corticosteroid therapy above 100 mg methylprednisolone. The statistical analysis revealed no significant differences in adverse events. CONCLUSION High-dose corticosteroid treatment (above 100 mg methylprednisolone) is associated with better overall survival rate at hospital discharge and ROSC outcomes. However, there is uncertainty regarding whether this treatment results in a benefit or harm to the favorable neurological outcomes at hospital discharge.
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Affiliation(s)
- Fa-Wei Zhou
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Emergency, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Chang Liu
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - De-Zhong Li
- Department of Emergency, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Yong Zhang
- Department of Nephrology, Jianli People's Hospital, Jianli, China.
| | - Fa-Chun Zhou
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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31
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Lee C, Otunla A, Brennan I, Aronson JK, Nunan D. Clinical trials of pharmacological interventions for SARS-CoV-2 published in leading medical journals report adherence but not how it was assessed. Br J Clin Pharmacol 2023. [PMID: 38158214 DOI: 10.1111/bcp.15992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 11/15/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024] Open
Abstract
AIMS Adherence to pharmacological interventions in clinical trials is crucial for accurate identification of beneficial and adverse outcomes. The ways in which adherence to interventions should be reported in trial publications are described in the Template for Intervention Description and Replication (TIDieR), a 12-item extension of the Consolidated Standards of Reporting Trials reporting guidelines. The objective of this study was to assess compliance with TIDieR Items 11 and 12 of randomized controlled trials (RCTs) of interventions in SARS-CoV-2 infection published in 5 selected journals during 2021. METHODS We assessed pharmacological interventions for SARS-CoV-2 infection reported in RCTs published in 2021 in the Annals of Internal Medicine, The BMJ, JAMA, The Lancet and The New England Journal for Medicine for compliance with TIDieR items addressing intervention adherence (Items 11 and 12). We calculated proportional adherence for pharmacological and comparator interventions where available. RESULTS We found 75 eligible RCTs. Twenty-eight (37%) reported results of SARS-CoV-2 vaccinations. Compliance with Items 11 and 12 could be assessed in 71 of these 75. Of the 71 RCTs, 37 (52%) reported how adherence was assessed (Item 11), and 70 reported adherence rates (Item 12). Only 1 of the 71 RCTs (1.4%, 0-7.6%) fully complied with TIDieR Items 11 and 12. CONCLUSION Half of RCTs of SARS-CoV-2 pharmacological interventions published in leading medical journals in 2021 complied with reporting of how adherence assessments were made and almost none complied with both TIDieR Items 11 and 12. The implications for interpretation, application and replication of findings based on these publications warrant consideration.
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Affiliation(s)
- Charlotte Lee
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Afolarin Otunla
- School of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
- University College London Hospitals, NHS Foundation Trust, London, UK
| | - Isabelle Brennan
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jeffrey K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Nunan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Arman BY, Brun J, Hill ML, Zitzmann N, von Delft A. An Update on SARS-CoV-2 Clinical Trial Results-What We Can Learn for the Next Pandemic. Int J Mol Sci 2023; 25:354. [PMID: 38203525 PMCID: PMC10779148 DOI: 10.3390/ijms25010354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has claimed over 7 million lives worldwide, providing a stark reminder of the importance of pandemic preparedness. Due to the lack of approved antiviral drugs effective against coronaviruses at the start of the pandemic, the world largely relied on repurposed efforts. Here, we summarise results from randomised controlled trials to date, as well as selected in vitro data of directly acting antivirals, host-targeting antivirals, and immunomodulatory drugs. Overall, repurposing efforts evaluating directly acting antivirals targeting other viral families were largely unsuccessful, whereas several immunomodulatory drugs led to clinical improvement in hospitalised patients with severe disease. In addition, accelerated drug discovery efforts during the pandemic progressed to multiple novel directly acting antivirals with clinical efficacy, including small molecule inhibitors and monoclonal antibodies. We argue that large-scale investment is required to prepare for future pandemics; both to develop an arsenal of broad-spectrum antivirals beyond coronaviruses and build worldwide clinical trial networks that can be rapidly utilised.
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Affiliation(s)
- Benediktus Yohan Arman
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Juliane Brun
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Michelle L. Hill
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, UK;
| | - Nicole Zitzmann
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Annette von Delft
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
- Centre for Medicine Discovery, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Falavigna M, de Araujo CLP, Barbosa AN, Belli KC, Colpani V, Dal-Pizzol F, da Silva RM, de Azevedo LCP, Dias MBS, do Amaral JLG, Dorneles GP, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Machado FR, Nunes MS, de Oliveira MS, Parahiba SM, Rosa RG, Santos VCC, Sobreira ML, Veiga VC, Xavier RM, Zavascki AP, Stein C, de Carvalho CRR. The II Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19 Joint Guidelines of the Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia and Sociedade Brasileira de Reumatologia. CRITICAL CARE SCIENCE 2023; 35:243-255. [PMID: 38133154 PMCID: PMC10734807 DOI: 10.5935/2965-2774.20230136-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To update the recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. METHODS Experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. RESULTS Twenty-one recommendations were generated, including strong recommendations for the use of corticosteroids in patients using supplemental oxygen and conditional recommendations for the use of tocilizumab and baricitinib for patients on supplemental oxygen or on noninvasive ventilation and anticoagulants to prevent thromboembolism. Due to suspension of use authorization, it was not possible to make recommendations regarding the use of casirivimab + imdevimab. Strong recommendations against the use of azithromycin in patients without suspected bacterial infection, hydroxychloroquine, convalescent plasma, colchicine, and lopinavir + ritonavir and conditional recommendations against the use of ivermectin and remdesivir were made. CONCLUSION New recommendations for the treatment of hospitalized patients with COVID-19 were generated, such as those for tocilizumab and baricitinib. Corticosteroids and prophylaxis for thromboembolism are still recommended, the latter with conditional recommendation. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and to promote resource economy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Juliana Carvalho Ferreira
- Sociedade Brasileira de Pneumologia e Tisiologia - São Paulo
(SP), Brazil
- Associação de Medicina Intensiva Brasileira -
São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
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He Q, Wang C, Wang Y, Chen G, Zhou Y, Wu Y, Zhong M. Efficacy and safety of glucocorticoids use in patients with COVID-19: a systematic review and network meta‑analysis. BMC Infect Dis 2023; 23:896. [PMID: 38124031 PMCID: PMC10734118 DOI: 10.1186/s12879-023-08874-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Currently, some meta-analyses on COVID-19 have suggested that glucocorticoids use can reduce the mortality rate of COVID-19 patients, utilization rate of invasive ventilation, and improve the prognosis of patients. However, optimal regimen and dosages of glucocorticoid remain unclear. Therefore, the purpose of this network meta-analysis is to analyze the efficacy and safety of glucocorticoids in treating COVID-19 at regimens. METHODS This meta-analysis retrieved randomized controlled trials from the earliest records to December 30, 2022, published in PubMed, Embase, Cochrane Library, CNKI Database and Wanfang Database, which compared glucocorticoids with placebos for their efficacy and safety in the treatment of COVID-19, Effects of different treatment regimens, types and dosages (high-dose methylprednisolone, very high-dose methylprednisolone, Pulse therapy methylprednisolone, medium-dose hydrocortisone, high-dose hydrocortisone, high-dose dexamethasone, very high-dose dexamethasone and placebo) on 28-day all-caused hospitalization mortality, hospitalization duration, mechanical ventilation requirement, ICU admission and safety outcome were compared. RESULTS In this network meta-analysis, a total of 10,544 patients from 19 randomized controlled trials were finally included, involving a total of 9 glucocorticoid treatment regimens of different types and dosages. According to the analysis results, the 28-day all-cause mortality rate was the lowest in the treatment with pulse therapy methylprednisolone (OR 0.08, 95% CI 0.02, 0.42), but the use of high-dose methylprednisolone (OR 0.85, 95% CI 0.59, 1.22), very high-dose dexamethasone (OR 0.95, 95% CI 0.67, 1.35), high-dose hydrocortisone (OR 0.64, 95% CI 0.34, 1.22), medium-dose hydrocortisone (OR 0.80, 95% CI 0.49, 1.31) showed no benefit in prolonging the 28-day survival of patient. Compared with placebo, the treatment with very high-dose methylprednisolone (MD = -3.09;95%CI: -4.10, -2.08) had the shortest length of hospital stay, while high-dose dexamethasone (MD = -1.55;95%CI: -3.13,0.03) and very high-dose dexamethasone (MD = -1.06;95%CI: -2.78,0.67) did not benefit patients in terms of length of stay. CONCLUSIONS Considering the available evidence, this network meta‑analysis suggests that the prognostic impact of glucocorticoids in patients with COVID-19 may depend on the regimens of glucocorticoids. It is suggested that pulse therapy methylprednisolone is associated with lower 28-day all-cause mortality, very high-dose methylprednisolone had the shortest length of hospital stay in patients with COVID-19. TRIAL REGISTRATION PROSPERO CRD42022350407 (22/08/2022).
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Affiliation(s)
- Qiaolan He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Chen Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yingqin Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Guannan Chen
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yue Zhou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yuanyuan Wu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China.
- Shanghai Key Laboratory of Lung Inflammation and Injury, 180 Fenglin Road, Shanghai, 200030, China.
- Shanghai Institute of Infectious Disease and Biosecurity, School of Public Health, Fudan University, Shanghai, 200030, China.
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Martin JH. The valley of death: why Australia failed to develop clinically effective drugs in COVID-19. Intern Med J 2023; 53:2175-2179. [PMID: 38050949 DOI: 10.1111/imj.16260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/03/2023] [Indexed: 12/07/2023]
Abstract
There is a paucity of public discussion of costs spent on drug trials during coronavirus disease 2019 (COVID-19) and their value, and of large public outlay on research funding for vaccine and drug development that did not deliver medicines nor vaccines for Australians. This oversight left us at the behest of global supply chains, politics and commercial cost-plus pricing for vaccines. It is possible that these outcomes were the result of some major cognitive biases and the failure of a clinical pharmacologist's voice in the leadership teams. Biases included unawareness of the complexities of taking interesting chemicals in vitro to development into therapeutic use that can be tolerated, show efficacy and have appropriate disposition in humans; lack of a systems approach to therapeutic development; and an understanding of the relevance and translatability of pharmacology, physiology and clinical drug development. We believe that reflecting on and addressing these biases will help Australia reposition itself better with a therapeutics and clinical trial strategy for future pandemics, built into the strategy of a Centre for Disease Control.
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Affiliation(s)
- Jennifer H Martin
- Clinical Pharmacology and Drug Repurposing and Medicines Research Program, University of Newcastle, Newcastle, New South Wales, Australia
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Jayasimhan D, Matthay M. Corticosteroids in adults with acute respiratory distress syndrome and severe pneumonia. BJA Educ 2023; 23:456-463. [PMID: 38009137 PMCID: PMC10667747 DOI: 10.1016/j.bjae.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 11/28/2023] Open
Affiliation(s)
- D. Jayasimhan
- Wellington Regional Hospital, Wellington, New Zealand
| | - M.A. Matthay
- University of California–San Francisco, San Francisco, CA, USA
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Li L, Sassen S, Hunfeld N, Smeets T, Ewoldt T, van den Berg SAA, Koch BCP, Endeman H. Population pharmacokinetics of dexamethasone in critically ill COVID-19 patients: Does inflammation play a role? J Crit Care 2023; 78:154395. [PMID: 37542750 DOI: 10.1016/j.jcrc.2023.154395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/12/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE The aim of this study is to design a population pharmacokinetic study to gain a deeper understanding of the pharmacokinetics of dexamethasone in critically ill COVID-19 patients in order to identify relevant covariates that can be used to personalize dosing regimens. METHODS Blood samples from critically ill patients receiving fixed-dose intravenous dexamethasone (6 mg/day) for the treatment of COVID-19 were sampled in a retrospective pilot study. The data were analyzed using Nonlinear Mixed Effects Modeling (NONMEM) software for population pharmacokinetic analysis and clinically relevant covariates were selected and evaluated. RESULTS A total of 51 dexamethasone samples from 18 patients were analyzed and a two-compartment model fit the data best. The mean population estimates were 2.85 L/h (inter-individual-variability 62.9%) for clearance, 15.4 L for the central volume of distribution, 12.3 L for the peripheral volume of distribution and 2.1 L/h for the inter-compartmental distribution clearance. The covariate analysis showed a significant negative correlation between dexamethasone clearance and CRP. CONCLUSIONS Dexamethasone PK parameters in ICU COVID patients were substantially different from those from non-ICU non-COVID patients, and inflammation may play an important role in dexamethasone exposure. This finding suggests that fixed-dose dexamethasone over several days may not be appropriate for ICU COVID patients.
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Affiliation(s)
- Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Sebastiaan Sassen
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicole Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tim Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tim Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Ramonfaur D, Salto-Quintana JN, Aguirre-García GM, Hernández-Mata NM, Villanueva-Lozano H, Torre-Amione G, Martínez-Reséndez MF. Cumulative steroid dose in hospitalized patients and COVID-19-associated pulmonary aspergillosis. J Hosp Infect 2023; 142:26-31. [PMID: 37499762 DOI: 10.1016/j.jhin.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Severe COVID-19 elicits a hyperimmune response frequently amenable to steroids, which in turn increase the risk for opportunistic infections. COVID-19 associated pulmonary aspergillosis (CAPA) is a complication known to be associated with immunomodulatory treatment. The role of cumulative steroid dose in the development of CAPA is unclear. This study evaluates the relationship between cumulative steroid dose in hospitalized individuals with COVID-19 pneumonia and the risk for CAPA. METHODS This retrospective cohort study includes 135 hospitalized patients with PCR-confirmed COVID-19 pneumonia at a tertiary centre in north Mexico. Patients who developed CAPA were matched by age and gender to two controls with COVID-19 pneumonia who did not develop CAPA defined and classified as possible, probable, or proven according to 2020 ECMM/ISHAM criteria. Cumulative steroid dose in dexamethasone equivalents was obtained from admission until death, discharge, or diagnosis of CAPA (whichever occurred first). The risk of CAPA by the continuous cumulative steroid dose was assessed using a logistic regression model. RESULTS Forty-five patients were diagnosed with CAPA and matched to 90 controls. Mean age was 61 ± 14 years, and 72% were male. Mean cumulative steroid dose was 66 ± 75 mg in patients without CAPA vs 195 ± 226 mg in patients with CAPA (P<0.001). The risk for CAPA increased with higher cumulative dose of steroids (OR 1.0075, 95% CI: 1.0033-1.0116). CONCLUSIONS Patients who developed CAPA had a history of higher cumulative steroid dose during hospitalization. The risk for CAPA increases ∼8% for every 10 mg of dexamethasone used.
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Affiliation(s)
- D Ramonfaur
- Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA, USA
| | - J N Salto-Quintana
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - G M Aguirre-García
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - N M Hernández-Mata
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - H Villanueva-Lozano
- Department of Infectious Diseases, ISSSTE Regional Monterrey, Monterrey, Nuevo Leon, Mexico
| | - G Torre-Amione
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico; The Methodist Hospital, Cornell University, Houston, TX, USA
| | - M F Martínez-Reséndez
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico; Epidemiological Surveillance Unit, Hospital San Jose-Tec Salud, Monterrey, Nuevo Leon, Mexico.
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Snow TAC, Arulkumaran N, Singer M, Choi SH. Effect of dexamethasone dose on outcomes in acute COVID-19 disease: A systematic review and meta-analysis. J Infect 2023; 87:490-497. [PMID: 37757919 DOI: 10.1016/j.jinf.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/20/2023] [Accepted: 09/22/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION The impact of different doses of dexamethasone on outcomes from acute COVID-19 pneumonia is unknown. METHODS We performed a systematic review and meta-analysis of randomised control trials comparing different doses of dexamethasone in adult patients with COVID-19. High dose dexamethasone treatment was defined as 12-24 mg daily, whereas low-dose treatment was 6-8 mg daily. Primary outcome was 28-day mortality. RESULTS Eight trials including 3469 patients were identified, with 1775 patients receiving high dose dexamethasone. There was no difference in mortality between patients receiving high dose or low-dose dexamethasone (22.0% vs. 20.2%; odds ratio 1.20 [95% confidence interval 0.86-1.67]; p = 0.29; I2 = 63%; TSA-adjusted CI [0.31-4.66]; very low QoE). Meta-regression did not demonstrate a dose-dependent effect of steroids on mortality. High dose dexamethasone was associated with an increased risk of hyperglycaemia (23.6% vs. 17.2%; 1.51 [1.19-1.92]; p = 0.0008; I2 = 0%; TSA-adjusted CI [0.90-2.54]; low QoE) but not secondary infections (14.3% vs. 15.0%; 0.87 [0.56-1.37]; p = 0.56; I2 = 72%; very low QoE). Risk of bias was low for seven of the eight studies. CONCLUSIONS The mortality of patients with acute COVID-19 receiving high-dose dexamethasone is similar to patients receiving low-dose dexamethasone, although high-dose dexamethasone is associated with an increased risk of hyperglycaemia.
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Affiliation(s)
| | | | - Mervyn Singer
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
| | - Sang-Ho Choi
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK; Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Olsen MH, Hansen ML, Lange T, Gluud C, Thabane L, Greisen G, Jakobsen JC. Detailed statistical analysis plan for a secondary Bayesian analysis of the SafeBoosC-III trial: a multinational, randomised clinical trial assessing treatment guided by cerebral oximetry monitoring versus usual care in extremely preterm infants. Trials 2023; 24:737. [PMID: 37974280 PMCID: PMC10655478 DOI: 10.1186/s13063-023-07720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Extremely preterm infants have a high mortality and morbidity. Here, we present a statistical analysis plan for secondary Bayesian analyses of the pragmatic, sufficiently powered multinational, trial-SafeBoosC III-evaluating the benefits and harms of cerebral oximetry monitoring plus a treatment guideline versus usual care for such infants. METHODS The SafeBoosC-III trial is an investigator-initiated, open-label, randomised, multinational, pragmatic, phase III clinical trial with a parallel-group design. The trial randomised 1601 infants, and the frequentist analyses were published in April 2023. The primary outcome is a dichotomous composite outcome of death or severe brain injury. The exploratory outcomes are major neonatal morbidities associated with neurodevelopmental impairment later in life: (1) bronchopulmonary dysplasia; (2) retinopathy of prematurity; (3) late-onset sepsis; (4) necrotising enterocolitis; and (5) number of major neonatal morbidities (count of bronchopulmonary dysplasia, retinopathy of prematurity, and severe brain injury). The primary Bayesian analyses will use non-informed priors including all plausible effects. The models will use a Hamiltonian Monte Carlo sampler with 1 chain, a sampling of 10,000, and at least 25,000 iterations for the burn-in period. In Bayesian statistics, such analyses are referred to as 'posteriors' and will be presented as point estimates with 95% credibility intervals (CrIs), encompassing the most probable results based on the data, model, and priors selected. The results will be presented as probability of any benefit or any harm, Bayes factor, and the probability of clinical important benefit or harm. Two statisticians will analyse the blinded data independently following this protocol. DISCUSSION This statistical analysis plan presents a secondary Bayesian analysis of the SafeBoosC-III trial. The analysis and the final manuscript will be carried out and written after we publicise the primary frequentist trial report. Thus, we can interpret the findings from both the frequentists and Bayesian perspective. This approach should provide a better foundation for interpreting of our findings. TRIAL REGISTRATION ClinicalTrials.org, NCT03770741. Registered on 10 December 2018.
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Affiliation(s)
- Markus Harboe Olsen
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark.
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark.
| | - Mathias Lühr Hansen
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Neonatology, Juliane Marie Centre, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Publich Health, Copenhagen University, Øster Farimagsgade 5, Copenhagen K, Denmark
| | - Christian Gluud
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- The Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, St Joseph's Healthcare-Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Gorm Greisen
- Department of Neonatology, Juliane Marie Centre, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- The Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Bourdin V, Bigot W, Vanjak A, Burlacu R, Lopes A, Champion K, Depond A, Amador-Borrero B, Sene D, Comarmond C, Mouly S. Drug-Drug Interactions Involving Dexamethasone in Clinical Practice: Myth or Reality? J Clin Med 2023; 12:7120. [PMID: 38002732 PMCID: PMC10672071 DOI: 10.3390/jcm12227120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Concomitant administration of multiple drugs frequently causes severe pharmacokinetic or pharmacodynamic drug-drug interactions (DDIs) resulting in the possibility of enhanced toxicity and/or treatment failure. The activity of cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), a drug efflux pump sharing localization and substrate affinities with CYP3A4, is a critical determinant of drug clearance, interindividual variability in drug disposition and clinical efficacy, and appears to be involved in the mechanism of numerous clinically relevant DDIs, including those involving dexamethasone. The recent increase in the use of high doses of dexamethasone during the COVID-19 pandemic have emphasized the need for better knowledge of the clinical significance of drug-drug interactions involving dexamethasone in the clinical setting. We therefore aimed to review the already published evidence for various DDIs involving dexamethasone in vitro in cell culture systems and in vivo in animal models and humans.
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Affiliation(s)
- Venceslas Bourdin
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - William Bigot
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Anthony Vanjak
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Ruxandra Burlacu
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Amanda Lopes
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Karine Champion
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Audrey Depond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Blanca Amador-Borrero
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Damien Sene
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Chloe Comarmond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Stéphane Mouly
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM UMR-S1144, Hôpital Fernand Widal, 75010 Paris, France
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Tekin A, Domecq JP, Valencia Morales DJ, Surapeneni KM, Zabolotskikh IB, Cartin-Ceba R, Clevenbergh P, Mesland JB, Claure-Del Granado R, Gavidia OY, Kumar VK, Kashyap R, Walkey AJ, Gajic O, Odeyemi Y. Biomarker-Concordant Steroid Administration in Severe Coronavirus Disease-2019. J Intensive Care Med 2023; 38:1003-1014. [PMID: 37226483 DOI: 10.1177/08850666231177200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Although corticosteroids have become the standard of care for patients with coronavirus disease-2019 (COVID-19) on supplemental oxygen, there is growing evidence of differential treatment response. This study aimed to evaluate if there was an association between biomarker-concordant corticosteroid treatment and COVID-19 outcomes. METHODS This registry-based cohort study included adult COVID-19 hospitalized patients between January 2020 and December 2021 from 109 institutions. Patients with available C-reactive protein (CRP) levels within 48 h of admission were evaluated. Those on steroids before admission, stayed in the hospital for <48 h, or were not on oxygen support were excluded. Corticosteroid treatment was biomarker-concordant if given with high baseline CRP ≥150 mg/L or withheld with low CRP (<150 mg/L) and vice-versa was considered discordant (low CRP with steroids, high CRP without steroids). Hospital mortality was the primary outcome. Sensitivity analyses were conducted using varying CRP level thresholds. The model interaction was tested to determine steroid effectiveness with increasing CRP levels. RESULTS Corticosteroid treatment was biomarker-concordant in 1778 (49%) patients and discordant in 1835 (51%). The concordant group consisted of higher-risk patients than the discordant group. After adjusting for covariates, the odds of in-hospital mortality were significantly lower in the concordant group than the discordant (odds ratio [95% confidence interval (C.I.)] = 0.71 [0.51, 0.98]). Similarly, adjusted mortality difference was significant at the CRP thresholds of 100 and 200 mg/L (odds ratio [95% C.I.] = 0.70 [0.52, 0.95] and 0.57 [0.38, 0.85], respectively), and concordant steroid use was associated with lower need for invasive ventilation for 200 mg/L threshold (odds ratio [95% C.I.] = 0.52 [0.30, 0.91]). In contrast, no outcome benefit was observed at CRP threshold of 50. When the model interaction was tested, steroids were more effective at reducing mortality as CRP levels increased. CONCLUSION Biomarker-concordant corticosteroid treatment was associated with lower odds of in-hospital mortality in severe COVID-19.
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Affiliation(s)
- Aysun Tekin
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Domecq
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Krishna Mohan Surapeneni
- Departments of Biochemistry, Molecular Virology, Research and Clinical Skills & Simulation, Panimalar Medical College Hospital & Research Institute, Chennai, Tamil Nadu, India
| | - Igor B Zabolotskikh
- Department of Anesthesiology, Intensive Care Medicine and Transfusiology, Kuban State Medical University with affiliation Territorial Hospital #2, Krasnodar, Russia
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | | | | | | | | | | | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allan J Walkey
- Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Evans Center of Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yewande Odeyemi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
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Inoue S, Kata Y, Suido Y, Nakashima K, Otsu Y, Takayasu H, Matsumoto Y, Kaneko T. Limited efficacy of low-dose dexamethasone for the treatment of severe COVID-19 pneumonia: A retrospective study. Respir Investig 2023; 61:760-767. [PMID: 37716284 DOI: 10.1016/j.resinv.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. Its symptoms range from mild to severe, with the latter often being life-threatening. This study aims to assess the effects of low-dose dexamethasone (DEX) in mild-to-severe COVID-19 pneumonia and examine the final clinical outcomes to identify the optimal therapeutic dose. METHODS Clinical data from 132 patients hospitalized for COVID-19 pneumonia between January and October 2021 at Yamato Municipal Hospital were retrospectively analyzed. Based on the ratio of peripheral arterial oxygen saturation (SpO2) to inspired fraction of oxygen (FiO2), patients were categorized into the mild (>450, n = 65), moderate (315-450, n = 55), and severe (<315, n = 12) pneumonia groups. The event of interest was defined as the worsening of the patient's condition during treatment (need to increase FiO2 > 0.1). Patients were treated with low-dose DEX (6.6 mg/day) for 10 days. RESULTS The event-free survival rate decreased significantly in patients with severe pneumonia compared with in those with mild and moderate pneumonia (Bonferroni-adjusted p < 0.02). A total of 16 patients were treated with high-dose corticosteroids because of severe hypoxia. Recovery was observed in all discharged patients with respiratory condition improvement. Low SpO2/FiO2 at admission was significantly associated with serum C-reactive protein levels. CONCLUSIONS For Japanese patients with COVID-19, severe pneumonia, and SpO2/FiO2 of <315, it may be necessary to administer a dose of corticosteroids of >6.6 mg DEX.
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Affiliation(s)
- Satoshi Inoue
- Yamato Municipal Hospital, Pulmonary Medicine, Japan.
| | - Yuki Kata
- Yamato Municipal Hospital, Pulmonary Medicine, Japan
| | | | | | - Yukiko Otsu
- Yamato Municipal Hospital, Pulmonary Medicine, Japan
| | | | | | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University, Graduate School of Medicine, Japan
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Stricker M. Managing hospitalized patients with COVID-19. JAAPA 2023; 36:16-20. [PMID: 37751251 DOI: 10.1097/01.jaa.0000977664.94343.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
ABSTRACT Treatment for COVID-19 has significantly changed since the beginning of the pandemic and continues to change as new evidence is published. This article describes which COVID-19 patients require hospitalization and how to manage hospitalized patients based on current evidence from randomized clinical trials.
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Affiliation(s)
- Mike Stricker
- Mike Stricker practices in hospital medicine at the Cleveland (Ohio) Clinic. The author has disclosed no potential conflicts of interest, financial or otherwise
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45
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Patanwala AE, Jager NGL, Radosevich JJ, Brüggemann R. An update on drug-drug interactions for care of the acutely ill in the era of COVID-19. Am J Health Syst Pharm 2023; 80:1301-1308. [PMID: 37368815 PMCID: PMC10516707 DOI: 10.1093/ajhp/zxad152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE To provide key pharmacological concepts underlying drug-drug interactions (DDIs), a decision-making framework, and a list of DDIs that should be considered in the context of contemporary acutely ill patients with COVID-19. SUMMARY DDIs are frequently encountered in the acutely ill. The implications of DDIs include either increased risk of drug toxicity or decreased effectiveness, which may have severe consequences in the acutely ill due to lower physiological and neurocognitive reserves in these patients. In addition, an array of additional therapies and drug classes have been used for COVID-19 that were not typically used in the acute care setting. In this update on DDIs in the acutely ill, we provide key pharmacological concepts underlying DDIs, including a discussion of the gastric environment, the cytochrome P-450 (CYP) isozyme system, transporters, and pharmacodynamics in relation to DDIs. We also provide a decision-making framework that elucidates the identification of DDIs, risk assessment, selection of alternative therapies, and monitoring. Finally, important DDIs pertaining to contemporary acute care clinical practice related to COVID-19 are discussed. CONCLUSION Interpreting and managing DDIs should follow a pharmacologically based approach and a systematic decision-making process to optimize patient outcomes.
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Affiliation(s)
- Asad E Patanwala
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, and Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Nynke G L Jager
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, and Radboudumc Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - John J Radosevich
- Department of Pharmacy Services, Dignity Health–St. Joseph’s Hospital & Medical Center, Phoenix, AZ, USA
| | - Roger Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, and Radboudumc Institute for Health Sciences Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Nijmegen, the Netherlands
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Kim MH, Shin HJ, Kim J, Jo S, Kim EK, Park YS, Kyong T. Novel Risks of Unfavorable Corticosteroid Response in Patients with Mild-to-Moderate COVID-19 Identified Using Artificial Intelligence-Assisted Analysis of Chest Radiographs. J Clin Med 2023; 12:5852. [PMID: 37762792 PMCID: PMC10532025 DOI: 10.3390/jcm12185852] [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: 07/27/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The prediction of corticosteroid responses in coronavirus disease 2019 (COVID-19) patients is crucial in clinical practice, and exploring the role of artificial intelligence (AI)-assisted analysis of chest radiographs (CXR) is warranted. This retrospective case-control study involving mild-to-moderate COVID-19 patients treated with corticosteroids was conducted from 4 September 2021, to 30 August 2022. The primary endpoint of the study was corticosteroid responsiveness, defined as the advancement of two or more of the eight-categories-ordinal scale. Serial abnormality scores for consolidation and pleural effusion on CXR were obtained using a commercial AI-based software based on days from the onset of symptoms. Amongst the 258 participants included in the analysis, 147 (57%) were male. Multivariable logistic regression analysis revealed that high pleural effusion score at 6-9 days from onset of symptoms (adjusted odds ratio of (aOR): 1.022, 95% confidence interval (CI): 1.003-1.042, p = 0.020) and consolidation scores up to 9 days from onset of symptoms (0-2 days: aOR: 1.025, 95% CI: 1.006-1.045, p = 0.010; 3-5 days: aOR: 1.03 95% CI: 1.011-1.051, p = 0.002; 6-9 days: aOR; 1.052, 95% CI: 1.015-1.089, p = 0.005) were associated with an unfavorable corticosteroid response. AI-generated scores could help intervene in the use of corticosteroids in COVID-19 patients who would not benefit from them.
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Affiliation(s)
- Min Hyung Kim
- Department of Internal Medicine, Division of Infectious Disease, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (M.H.K.); (Y.S.P.)
| | - Hyun Joo Shin
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (H.J.S.); (E.-K.K.)
- Center for Digital Health, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea
| | - Jaewoong Kim
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (J.K.); (S.J.)
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sunhee Jo
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (J.K.); (S.J.)
| | - Eun-Kyung Kim
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (H.J.S.); (E.-K.K.)
- Center for Digital Health, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea
| | - Yoon Soo Park
- Department of Internal Medicine, Division of Infectious Disease, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (M.H.K.); (Y.S.P.)
| | - Taeyoung Kyong
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Republic of Korea; (J.K.); (S.J.)
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Şimşek-Yavuz S. COVID-19: An Update on Epidemiology, Prevention and Treatment, September-2023. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2023; 5:165-187. [PMID: 38633552 PMCID: PMC10986731 DOI: 10.36519/idcm.2023.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 04/19/2024]
Abstract
After a downward trend for more than 12 months, the incidence of COVID-19 has increased in the last months. Although COVID-19 is not as frequent as in the first years of the pandemic, case numbers are still very high, and it causes a significant number of deaths. COVID-19 is not seen with a predictable frequency, at least two times more deadly than the flu, continues as an epidemic, and has not reached the endemic level yet. Currently, the Omicron strains EG.5 and XBB.1.16 are dominant worldwide. Although BA.2.86 and FLip variants, including FL.1.5.1 are not widespread at the moment, both were shown to be highly immune-evasive and require close monitoring. Prevention of COVID-19 relies on vaccinations, surveillance, proper ventilation of enclosed spaces, isolation of patients, and mask usage. Currently, monovalent COVID-19 vaccines, including XBB.1.5 Omicron SARS-CoV-2, are recommended for both primary and booster vaccinations against COVID-19. Monovalent vaccines, including only original SARS-CoV-2 strain, and bivalent vaccines, including original virus plus BA4/5 variant, are no longer recommended against COVID-19. Booster vaccination with XBB.1.5 containing vaccine should be prioritized for patients at high risk for severe COVID-19. Bacillus Calmette-Guérin (BCG) vaccination does not seem to be effective in preventing COVID-19. At the current phase of the pandemic, nirmatrelvir/ritonavir, remdesivir, molnupiravir, sotrovimab (for patients from XBB.1.5 variant dominant settings), and convalescent plasma can be considered for the treatment of high-risk early-stage outpatients with COVID-19, while hospitalized patients with more severe disease can be treated with dexamethasone, anti cytokines including tocilizumab, sarilumab, baricitinib, and tofacitinib and antithrombotic agents including enoxaparin. Remdesivir oral analogues and ensitrelvir fumarate are promising agents for treating acute COVID-19, which are in phase trials now; however, ivermectin, fluvoxamine, and metformin were shown to be ineffective.
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Affiliation(s)
- Serap Şimşek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Türkiye
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48
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Świerczek A, Jusko WJ. Anti-inflammatory effects of dexamethasone in COVID-19 patients: Translational population PK/PD modeling and simulation. Clin Transl Sci 2023; 16:1667-1679. [PMID: 37386717 PMCID: PMC10499420 DOI: 10.1111/cts.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/24/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
Dexamethasone (DEX) given at a dose of 6 mg once-daily for 10 days is a recommended dosing regimen in patients with coronavirus disease 2019 (COVID-19) requiring oxygen therapy. We developed a population pharmacokinetic and pharmacodynamic (PopPK/PD) model of DEX anti-inflammatory effects in COVID-19 and provide simulations comparing the expected efficacy of four dosing regimens of DEX. Nonlinear mixed-effects modeling and simulations were performed using Monolix Suite version 2021R1 (Lixoft, France). Published data for DEX PK in patients with COVID-19 exhibited moderate variability with a clearance of about half that in healthy adults. No accumulation of the drug was expected even with daily oral doses of 12 mg. Indirect effect models of DEX inhibition of TNFα, IL-6, and CRP plasma concentrations were enacted and simulations performed for DEX given at 1.5, 3, 6, and 12 mg daily for 10 days. The numbers of individuals that achieved specified reductions in inflammatory biomarkers were compared among the treatment groups. The simulations indicate the need for 6 or 12 mg daily doses of DEX for 10 days for simultaneous reductions in TNFα, IL-6, and CRP. Possibly beneficial is DEX given at a dose of 12 mg compared to 6 mg. The PopPK/PD model may be useful in the assessment of other anti-inflammatory compounds as well as drug combinations in the treatment of cytokine storms.
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Affiliation(s)
- Artur Świerczek
- Department of Pharmacokinetics and Physical Pharmacy, Faculty of PharmacyJagiellonian University Medical CollegeKrakówPoland
| | - William J. Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical SciencesState University of New York at BuffaloBuffaloNew YorkUSA
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Salton F, Confalonieri P, Torregiani C, Ruaro B, Confalonieri M. Higher, but Not Too High, Dose Is Only One Determinant of Corticosteroid Treatment Success in Severe COVID-19. Ann Am Thorac Soc 2023; 20:1371. [PMID: 37343288 PMCID: PMC10502891 DOI: 10.1513/annalsats.202304-329le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/21/2023] [Indexed: 06/23/2023] Open
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50
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Kosovali BD, Mutlu NM. Global scientific outputs of extracorporeal membrane oxygenation in COVID-19: A bibliometric overview. Perfusion 2023; 38:1153-1164. [PMID: 35635047 PMCID: PMC9152629 DOI: 10.1177/02676591221105405] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIM Although the number of global studies on ECMO, which is an important support system in the treatment of COVID-19 related respiratory failure, has increased in recent months, there is still no bibliometric study on the use of ECMO in COVID-19 in the literature. The aim of this study is to analyze the scientific articles on the use of ECMO in COVID-19 by statistical and bibliometric methods. METHOD Articles published between 2019-2022 about the use of ECMO in COVID-19 were obtained from the Web of Science (WoS) database and analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. Network visualization maps were used to identify effe analysis and trending topics. RESULTS A total of 1197 publications were found. 758 (63.3%) of these publications were articles. The top 3 contributing countries to the literature were USA (257, 33.9%), Germany (102, 13.4%) and Japan (87, 11.5%). The top 3 most active institutions were League of European Research Universities (90), Harvard University (50), and Udice French Research Universities (39). The top 3 journals with the highest count of publications were ASAIO Journal (n = 36), Frontiers in Medicine (22), and Perfusion-UK (n = 20). According to the average count of citations per article, the most influential journals were JAMA (1319), Intensive Care Medicine (327), and Lancet (95.7), respectively. We have shared a summary of 758 articles in this comprehensive bibliometric study on the use of ECMO in COVID-19. CONCLUSION It can be said that the use of ECMO in COVID-19 has been the trending topic recently and most of the studies are from countries in the ELSO Awards of Excellence list which indicates that the follow-up of ECMO in certain centers and teams can also be influencing the publications. This article can be a useful resource for clinicians, scientists, and students concerning global output for ECMO use in COVID-19.
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Affiliation(s)
| | - Nevzat M Mutlu
- Department of Critical Care,
Ankara
City Hospital, Ankara, Turkey
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