Pulmonary Disorders I

Corticosteroids in COVID-19 (see the Infectious Diseases I chapter for further information)

Currently, clinical practice guidelines strongly recommend the use of dexamethasone in ICU

patients with COVID-19 (Table 5).

The landmark RECOVERY clinical trial compared dexamethasone 6 mg daily up to 10 days total

administered either orally or intravenously compared to usual care alone in 6425 hospitalized

patients with COVID-19 (N Engl J Med 2021;384:693-704). Among 1007 patients in the prespecified

subgroup analysis requiring invasive MV, the 28-day mortality rate was significantly lower in the

dexamethasone group (29.3%) than in the usual care group (41.4%) (RR 0.64; 95% CI, 0.51–0.81).

In addition, the probability of hospital discharge within 28 days among those receiving invasive

MV significantly improved in patients receiving dexamethasone over usual care (RR 1.45; 95%

CI, 1.13–1.85). Moreover, MV cessation was more likely with dexamethasone than with usual care

(RR 1.47; 95% CI, 1.20–1.78). Similarly, use of dexamethasone lowered overall mortality among

all hospitalized patients compared with usual care. However, a survival benefit was only observed

among patients with COVID-19 requiring oxygen support (both invasive and noninvasive) over

those without any respiratory support.

The CoDEX clinical trial randomized 299 adult patients with COVID-19 with moderate to

severe ARDS to either dexamethasone (20 mg intravenously daily over 5 days followed by 10 mg

16). The primary end point was ventilator-free days during the initial 28 days consisting of the

number of days alive and liberation from MV for 48 hours or more. The mean number of ventilator-

free days in the dexamethasone and usual care groups was 6.6 days and 4.0 days (adjusted difference

of 2.26 days; 95% CI, 0.2–4.38; p=0.04), respectively. No differences were observed between study

groups for secondary aims, including 28-day mortality, ICU-free days, overall MV days, or risk of

adverse events. A limitation of this trial is that it was terminated early because of the publication

of the RECOVERY trial findings. This may have introduced bias despite showing a positive benefit

associated with dexamethasone.

Source

Summary

GRADE Recommendation

www.covid19treatmentguidelines.nih.gov

Last updated February 29, 2024

Recommends dexamethasone for

most patients requiring mechanical

ventilation or ECMO

Strong recommendation

www.idsociety.org/COVID19guidelines

Last updated September 25, 2020

Recommends dexamethasone rather

than no dexamethasone

Strong recommendation,

moderate certainty of evidence

of systemic corticosteroids over

not using corticosteroids

dexamethasone over other

corticosteroid derivatives

moderate level of evidence

very low level of evidence