Corticosteroids will help in survival of aged sufferers with extreme COVID-19
The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected over 54.76 million people and killed over 1.32 million people worldwide. Advancing age is one of the most important risk factors predicting severe disease progression, followed by the need for ventilation and intensive care.
A new study group based in France looked at the survival rates of elderly patients with COVID-19 who were given corticosteroids. Their study entitled “Corticosteroids are associated with increased survival in older people with severe SARS-Cov2 infection” was published on medRxiv *, the preprint server.
Older people are at higher risk of serious illness and death from COVID-19. The authors state that the population over 65 years of age makes up 9 percent worldwide. However, among the deaths from COVID-19, 80 percent are elderly. Around 30 to 40 percent of the worldwide registered cases of COVID-19 are older people. This makes this population a major concern in the treatment and management of COVID-19.
Steroids in COVID-19
The World Health Organization (WHO) has recommended the use of systemic (intravenous) corticosteroids for all adult patients with severe and critical COVID-19. However, there are very few studies specifically looking at the effectiveness of using these steroids in the elderly with severe COVID-19.
Recently, reports from the RECOVERY study – an Oxford University research project investigating COVID-19-related treatments – showed that there was no difference in survival for patients treated with dexamethasone (a corticosteroid) compared to patients who were that weren’t. However, in this RECOVERY study, there were a wide range of patients with varying degrees of infection, so it was difficult to draw firm conclusions, the authors said.
France and steroid use in the elderly
In France and some other countries, the systematic use of corticosteroids is not recommended in patients over 70 years of age. Because of the high risk of death in elderly patients with severe COVID-19, corticosteroids have been widely administered to people over 80 in France since the beginning of the pandemic.
This study was conducted using medical data and experience of steroid treatment in the elderly in France to evaluate its effectiveness in treating severe SARS-CoV-2 infections (patients with pneumonia requiring oxygen) in the elderly.
This was an observational comparative study that collected all data related to routine care for COVID-19 patients. For this study, data were collected from geriatric and infectious disease units in 36 different hospitals in France and Luxembourg. Patients enrolled between March 1 and April 30, 2020 were enrolled in the study.
The participants in this study were all over 80 years old and had SARS-CoV-2 infection, which was confirmed by PCR-RT tests (Polymerase Chain Reaction Reverse Transcription) or suggestive CT scan images. They needed more than 3 liters of oxygen per minute and had C-reactive protein levels above 40 mg / L (which indicates inflammation).
Patient survival up to day 14 was the primary measure of outcome. The percentage of those discharged from hospital to home / rehabilitation on day 14 was also recorded. All side effects of therapy were also recorded for analysis. These were recorded separately by one of the doctors on the team.
Two treatment strategies were compared:
- Treatment group – those who received at least one dose of corticosteroids ≥ 0.4 mg / kg / day equivalent of prednisone. Participants in this group were started on corticosteroids within a “grace period” of 72 hours after the start of the study.
- Control group – those who receive standard supportive care.
All patients were followed up at the start of the study. Events recorded at the start of the study included death, loss of follow-up care, end of follow-up care at least on the 14th day after the start of the study.
The overall results of this study can be summarized as follows:
- A total of 267 elderly patients with severe COVID-19 were included in the analysis. The average age of the participants was 86 years (between 83 and 90 years). 95 percent had confirmed PCR-RT for COVID-19.
- 96 participants were assigned to the treatment group. Of these steroid treatments were as follows:
- 51 (53.7%) received methylprednisolone
- 22 (23.2%) received prednisone
- 15 (15.8%) received dexamethasone
- 4 (4.2%) received prednisolone
- 3 (3.2%) received hydrocortisone
- The use of corticosteroids was associated with increased survival (weighted hazard ratio) [wHR] 0.66, 95% CI 0.44 to 0.97)
- At the follow-up examination, 41 patients (42.7 percent) and 86 patients (50.2 percent) died before the 14th day in the treatment or control group (hazard ratio HR 0.76, 95% CI 0.52 to 1, 09).
- Regarding the proportion of patients discharged home / rehabilitation on day 14, both the treatment and control groups had similar numbers (weighted relative risk wRR 1.11, 95% CI 0.68 to 1.81 ).
- A total of 22 (or 16.7 percent) of the patients in the treatment group who received steroids developed side effects, and 11 (or 6.4 percent) in the control group developed side effects to treatment.
- The side effects in the treatment and control groups were as follows:
- Elevated blood sugar or hyperglycemia (6.1 percent versus 0.6 percent)
- Heart failure (2.3 percent versus 0.6 percent)
- Confusion (3 percent versus 1.2 percent)
- Infections (1.5 percent versus 0 percent)
Conclusions and implications
The study’s authors concluded that steroids were associated with a “significant increase” in overall survival up to day 14 in older patients over 80 years of age who had to be hospitalized for severe COVID-19. The authors write: “Overall, our results support the WHO guidelines and extend them to patients over 80 years of age without contraindications.”
* Important NOTE
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or treated as established information.