Corticosteroids can help in survival of elderly patients with severe COVID-19

By Dr. Ananya Mandal, MDNov 16 2020

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over 54.76 million people around the world and claimed the lives of over 1.32 million. Increasing age is one of the most important risk factors that predict a severe course of the illness, followed by the need for ventilation and intensive care treatment.

A new study group based in France have looked at the rates of survival among elderly patients with COVID-19 who were administered with corticosteroids. Their study, titled “Corticosteroids are associated with increased survival in elderly presenting severe SARS-Cov2 infection,” has been released on medRxiv* the preprint server.

Study: Corticosteroids are associated with increased survival in elderly presenting severe SARS-Cov2 infection. Image Credit: NIAID

This news article was a review of a preliminary scientific report that had not undergone peer-review at the time of publication. Since its initial publication, the scientific report has now been peer reviewed and accepted for publication in a Scientific Journal. Links to the preliminary and peer-reviewed reports are available in the Sources section at the bottom of this article. View Sources

Study background

The aged are at a greater risk of severe disease and death caused by COVID-19. The authors state that around the world, the population over 65 years makes up 9 percent. However, among deaths due to COVID-19, 80 percent are elderly. Around 30 to 40 percent of cases of COVID-19 recorded around the world are elderly, they added. This makes this population an important concern when treating and managing COVID-19.

Steroids in COVID-19

The World Health Organization (WHO) has recommended the use of systemic (given intravenously) corticosteroids for all adult patients with severe and critical COVID-19. There are, however, very few studies that specifically look at the effectiveness of the use of these steroids among the elderly with severe COVID-19.

RECOVERY trial

Recently, reports from the RECOVERY trial – a research project led by Oxford University aimed at exploring COVID-19-related treatments – showed that there was no difference in survival of patients who were treated with dexamethasone (a corticosteroid) compared to those who were not. However, in this RECOVERY study, there was a wide range of patients with different severities of infection, and so it was difficult to draw firm conclusions, said the authors.

France and use of steroids in the elderly

In France and some other nations, systematic use corticosteroids for patients over the age of 70 are not recommended. However, due to the high risk of deaths among older patients with severe COVID-19, corticosteroids have been frequently administered to those over 80 in France since the start of the pandemic.

This study was undertaken with medical data and experiences of steroid treatment among the elderly in France to date to assess its efficacy as a treatment for severe SARS-CoV-2 infection (those with pneumonia requiring oxygen) in elderly patients.

Study design

This was a comparative observational study that gathered all the routine care data for COVID-19 patients. For this study, data from geriatric and infectious diseases wards from 36 different hospitals in France and Luxembourg, were gathered. Patients admitted between March 1 and April 30, 2020, were included in the study.

Participants of this study were all over 80 and had SARS-CoV-2 infection confirmed with polymerase chain reaction reverse transcription (PCR-RT) tests or suggestive CT-scan images. They required over 3 litres per minute of oxygen and had C-reactive protein levels over 40 mg/l (indicative of inflammation).

The survival of the patients until day 14 was the primary measure of outcome. The percentage of those who were discharged from hospital to home/rehabilitation on day 14 was also recorded. All adverse effects of therapy were recorded for analysis as well. These were recorded by one of the physicians on the team separately.

Two treatment strategies were compared:

• Treatment group - those receiving at least one dose of corticosteroids ≥0.4 mg/kg/day equivalent of prednisone. The participants in this group were started on corticosteroids within a “grace period” of 72h after baseline.
• Control group – those receiving standard supportive care.

For all patients, a follow-up period started at baseline. The events recorded at baseline included death, loss to follow-up, end of follow-up at least at day 14 after baseline.

Findings

Overall results of this study can be summarized as:

• A total of 267 elderly patients with severe COVID-19 were included in the analysis. The median age of the participants was 86 years (ranging between 83 and 90 years). 95 percent had confirmed PCR-RT for COVID-19.
• Of these, 96 participants were assigned to the treatment group. Of these steroid treatments was as follows:
  • 51 (53.7%) received methylprednisolone
  • 22 (23.2%) received prednisone
  • 15 (15.8%) received dexamethasone
  • 4 (4.2%) received prednisolone
  • 3 (3.2%) received hydrocortisone
• Use of corticosteroids was associated with increased survival (weighted hazard ratio [wHR] 0.66, 95% CI 0.44 to 0.97)
• On follow up 41 patients (42.7 percent) and 86 patients (50.2 percent) died before day 14 in the treatment and control groups, respectively (Hazard ratio HR 0.76, 95% CI 0.52 to 1.09)
• Regarding the proportion of patients discharged to home/rehabilitation at day 14, both treatment and control groups had similar numbers (Weighted Relative risk wRR 1.11, 95% CI 0.68 to 1.81)
• A total of 22 (or 16.7 percent) of patients on the treatment group receiving steroids developed adverse effects, and 11 (or 6.4 percent) on the control group developed adverse effects on treatment.
• Adverse effects were as follows in treatment and control groups, respectively –
  • Raised blood sugar or hyperglycemia (6.1 percent vs 0.6 percent)
  • Heart failure (2.3 percent vs 0.6 percent)
  • Confusion (3 percent vs 1.2 percent)
  • Infections (1.5 percent vs 0 percent)

Conclusions and implications

The study authors concluded that steroids were associated with a “significant increase” in by day 14 of overall survival among elderly patients over the age of 80 years who had to be hospitalized for severe COVID-19. Authors write, “Altogether, our results support the WHO guidelines, and expand them to patients over 80 years old without contra-indication.”

This news article was a review of a preliminary scientific report that had not undergone peer-review at the time of publication. Since its initial publication, the scientific report has now been peer reviewed and accepted for publication in a Scientific Journal. Links to the preliminary and peer-reviewed reports are available in the Sources section at the bottom of this article. View Sources