Journal article

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Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report

Author(s): The RECOVERY Collaborative Group

N Engl J Med July 17, 2020

Respiratory infections
General respiratory patient care
Public health

Digest Author(s): Stylianos Loukides, e-Learning Director / 19 July, 2020

Treatment for Covid-19 severe diseases still remains a controversial issue. The absence of reliable evidence from well designed randomized clinical trials strengthen the uncertainty of treatment interventions. Some small reports recommended steroids for severe cases.However, the whole issue remains controversial since clinical practice failed to support the above recomendations.

The current study controlled, open-label Randomized Evaluation of Covid-19 Therapy (RECOVERY) trial aimed to determine the role of dexamethasone in patients hospitalized with Covid-19. The authors randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (17% lower risk for dexamethasone group). Further analysis showed that in the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%, 36% lower risk, and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 18% lower risk. The above statistically significant differences were not observed in those patients who were receiving no respiratory support at randomization.

In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. The greatest effect regarding discharge within 28 days was seen among patients who were receiving invasive mechanical ventilation at randomization.

3 major comments:

  • 60% of the patients had a co-existing disease. The mean age was 66 years old.
  • The initial clinical phase is closely related to the primary outcome of the study, which was mortality.
  • Early intubation has an additive effect on prognosis.

We need more details in order to determine the responders and to establish a more personalized approach.