Efficacy and safety of corticosteroids in patients with SARS-CoV-2 infection still are debated. Because large randomized clinical trials (RCTs) and a well-conducted meta-analysis on the use of corticosteroids, focused on patients with coronavirus disease (COVID-19) in intensive care units, recently were published, a meta-analysis of RCTs on corticosteroids therapy in patients with different disease severity was performed to evaluate the effect on survival.

A meta-analyses of RCTs was performed. Patients admitted to hospital. Patients with coronavirus disease. Administration of corticosteroids.

A search was performed for RCTs of adult patients with acute hypoxemic failure related to 2019-nCoV infection who received corticosteroids versus any comparator. The primary endpoint was mortality rate.

Five RCTs involving 7,692 patients were included.

Overall mortality of patients treated with corticosteroids was slightly but significantly lower than mortality of controls (26% v 28%, relative risk {RR} = 0.89 [95% confidence interval {CI} 0.82-0.96], p = 0.003).

The same beneficial effect was found in the subgroup of patients requiring mechanical ventilation (RR = 0.85 [95% CI 0.72-1.00], p = 0.05 number needed to treat {NNT} = 19).

Remarkably, corticosteroids increased mortality in the subgroup of patients not requiring oxygen (17% v 13%, RR = 1.23 [95% CI 1.00-1.62], p = 0.05 number needed to harm {NNH} = 29).

Tests for comparison between mechanically ventilated subgroups and those not requiring oxygen confirmed that treatment with corticosteroids had a statistically significant different effect on survival. Patients treated with corticosteroids had a significantly lower risk of need for mechanical ventilation.

Corticosteroids may be considered in severe critically ill patients with COVID-19 but must be discouraged in patients not requiring oxygen therapy. Urgently, further trials are warranted before implementing this treatment worldwide.

For Daniel Dressler this analysis further confirms guideline recommendations (NEJM JW Infect Dis Jan 2021 and BMJ 2020; 371:3379): Patients with severe COVID-19 infections who are intubated or require oxygen therapy should receive immediate corticosteroid therapy. Those with less-severe infections who do not require oxygen therapy should not receive corticosteroid therapy, whether managed as inpatients or outpatients. I’ve seen some low-risk inpatients receiving steroid therapy — clinicians should accurately assess patients’ indications for this intervention.