UMEM Educational Pearls

Category: Critical Care

Title: Dexamethasone: Improving Mortality in COVID-19?

Keywords: dexamethasone, steroids, respiratory failure, COVID-19, SARS-CoV-2, RECOVERY (PubMed Search)

Posted: 7/14/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

The RECOVERY (Randomized Evaluation of COVid-19 thERapY) investigators recently published a non-peer reviewed article on their findings utilizing dexamethasone to treat patients with COVID-19. 

Rx: Dexamethasone 6mg daily* x 10 days (PO or IV) *or steroid equivalent

  • 2104 in the dexamethasone group vs 4321 in the “usual care” group
  • Did not exclude children or pregnant/breastfeeding mothers
  • Follow-up at 28 days, hospital discharge, or death

Primary outcome:         All-cause mortality at 28-days

Secondary outcomes: 

  • Major arrhythmia
  • Time to discharge from hospital
  • Duration of mechanical ventilation
  • Need for renal replacement therapy
  • In patients not ventilated at enrollment, need for intubation/ECMO & death

Results:

  • Decrease in overall mortality at 28-days with 3% absolute risk reduction.
    • NNT of 25 in patients requiring O2, HFNC, or NIV
    • NNT of 8 in patients requiring invasive mechanical ventilation
  • More mortality benefit seen the higher the respiratory support required, with no benefit and apparent trend towards increased mortality in the group not requiring any respiratory support at all. 
  • When stratified by symptoms < or > 7 days, mortality benefit only seen in the >7 days group (which was more of the ventilated patients).
  • Less progression to intubation, shorter hospital duration, greater likelihood of hospital discharge.

Limitations:

  • Not yet peer-reviewed, haven't seen all the data, additional analyses could be helpful in determining if treatment effect is real
  • Unblinded study
  • 7% of control group received dexamethasone

 

Bottom Line: Strongly consider admininstering dexamethasone to your patients with known COVID-19 who require respiratory support, and look for the peer-reviewed publication from the RECOVERY Trial investigators.

 

References

Horby P, Lim WS, Emberson et al. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1 (Accessed July 14th, 2020)