Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Clinical Question
Can corticosteroids reduce mortality in hospitalized patients with COVID-19 who require oxygen or ventilation? Can postexposure prophylaxis with hydroxychloroquine improve outcomes?
Bottom line
Corticosteroids reduce mortality in hospitalized patients with COVID-19 who require oxygen or ventilatory support. In healthy people, postexposure prophylaxis with hydroxychloroquine is not effective. 2c
Reference
Study design: Other
Funding:
Setting: Inpatient (any location)
Synopsis
Research Brief #36: The RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial randomized 11,320 hospitalized patients with suspected or confirmed COVID-19 into 1 of 6 open-label arms: azithromycin, lopinavir-ritonavir, tocilizumab, convalescent plasma, low-dose dexamethasone (6 mg once daily for 10 days), or usual care. This study, from researchers at Oxford University, reports the results from the comparison of low-dose dexamethasone (n = 2104) with usual care (n = 4321). The primary outcome was 28-day mortality. The mean age of participants was 66 years, 36% were women, and 56% had at least one major comorbidity. The groups were balanced at baseline. At the time the manuscript was written, 82% of patients had a positive test result for COVID-19, 9% had a test result pending, and 9% apparently had a negative result. Follow-up was fairly complete (95%) and there were few crossovers (7% in the usual care group received dexamethasone). The use of remdesivir was rare. Mortality was significantly reduced overall (21.6% vs 24.6%; P < .001; number needed to treat [NNT] = 33). The degree of benefit was strongly associated with the severity of illness. The benefit was greatest for the patients who required mechanical ventilation (29.0% vs 40.7%; P < .001; NNT = 9); patients who required oxygen but not mechanical ventilation benefitted somewhat less (21.5% vs 25.0%; P = .002; NNT = 29). No benefit (and, in fact, a trend toward harm) was observed for hospitalized patients who did not require either oxygen or mechanical ventilation (17.0% vs 13.2%; P = NS). The latter finding has important implications for the care of outpatients who do not receive oxygen: They should not be given a glucocorticoid in the absence of another compelling indication.
Research Brief #37: This study is different from all other hydroxychloroquine (HCQ) studies in that it studied postexposure prophylaxis in healthy patients. The authors identified patients who had either a high-risk exposure to someone with confirmed COVID-19 — defined as exposure of at least 10 minutes, from less than 6 feet away, and without facial covering — or a moderate-risk exposure, which included a face mask but no eye shield. The authors randomized 821 initially asymptomatic persons within 4 days of exposure to receive hydroxychloroquine (800 mg once, then 600 mg in 6 to 8 hours, and then 600 mg once daily for 4 days) or matching placebo. The primary outcome was laboratory confirmed or clinically suspected COVID-19 (testing was not yet widely available) in the 14 days after enrollment. Healthcare workers accounted for two-thirds of the patients; the median age of all patients was 40 years. There was no difference between groups in the primary outcome: 49/414 (11.8%) in the HCQ group reported infection versus 58/407 (14.3%) in the placebo group (risk difference -2.4%; 95% CI -7.0 to 2.2). The findings were the same at 5, 10, and 14 days.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA