Cardiac biomarker-guided corticosteroid dosing feasible, safe in COVID-19 pneumonia
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An individualized, biomarker-guided approach to corticosteroid dosing utilizing C-reactive protein for COVID-19-related pneumonia reduced patients’ cumulative steroid exposure and increased the number of hospital- and oxygen-free days.
This novel approach for treating pneumonia and hypoxemic respiratory failure was quickly and successfully adapted at the onset of the COVID-19 pandemic and was also safe in this population, according to Yewande Odeyemi, MD, assistant professor in the division of pulmonary and critical care at Mayo Clinic in Rochester, Minnesota.
“Prior to COVID-19, corticosteroid use in community-acquired pneumonia was both controversial and undefined,” Odeyemi said during a presentation at the American Heart Association Scientific Sessions. “Our goal was to assess the feasibility and safety of an individualized, biomarker-guided corticosteroid-dosing approach utilizing C-reactive protein compared to usual care in patients with community-acquired pneumonia and acute hypoxemic respiratory failure. Our secondary goal was to assess any potential preliminary efficacy of this strategy on noncardiovascular outcomes. This was quickly adapted to include COVID-19 pneumonia at the beginning of the pandemic with the addition of cardiovascular outcomes.”
The pilot randomized controlled trial was conducted at Mayo Clinic from March 2020 to November 2020. The trial included patients hospitalized with community-acquired pneumonia including COVID-19 and acute hypoxemic respiratory failure (n = 44). Methylprednisolone was administered daily and dosed based on CRP levels or patients were treated with usual care.
“Usual care did change as the standard of care for COVID-19 infection evolved,” Odeyemi said. “Prior to July 2020, steroids were contraindicated in COVID-19 infection. After the publication of the results of the RECOVERY trial, steroids became standard of care in a fixed-dose regimen.”
The primary outcome was feasibility. Secondary noncardiovascular outcomes included cumulative steroid exposure, hospital-free days, oxygen-free days, in-hospital mortality, advanced respiratory support, hyperglycemia and delirium. Secondary CV outcomes included requirement for vasopressor therapy, new-onset or worsening arrhythmia, myocardial injury as measured by troponin or LV dysfunction, or new diagnosis of right ventricular dysfunction.
Odeyami reported no significant between-group differences in age, sex, comorbidities and use of oxygen-delivery devices. Ninety-three percent of patients enrolled had confirmed SARS-CoV-2 infection. The treatment protocol was followed in 90% of patients.
Median time to corticosteroid administration was 24.3 hours after admission and 3.6 hours after randomization to the intervention arm of the trial.
By day 3, patients in the intervention arm had significantly lower CRP levels compared with the usual care arm (P = .012). Troponin levels were no different between the arms on any day.
Patients in the intervention arm had significantly lower cumulative exposure to corticosteroids compared with the usual care arm (median, 256 vs. 135; P = .009), according to the presentation.
In addition, patients in the intervention arm had more hospital-free days (17 vs. 21; P = .037) and oxygen-free days (18.5 vs. 24; P = .002) compared with the usual care arm.
Odeyemi said these difference in hospital- and oxygen-free days persisted with the exclusion of patients in both groups who did not receive corticosteroids.
Moreover, Odeyemi reported no difference in CV outcomes between the groups.
“An individualized, biomarker-guided approach to corticosteroid use in pneumonia is feasible and safe with potential benefits, including lower cumulative exposure to corticosteroids, increased oxygen-free days, and increased hospital-free days,” Odeyemi said. “Future larger pragmatic trials with enrichment strategies are needed to evaluate the efficacy and effectiveness of this novel approach.”
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Odeyemi Y, et al. Rapid-fire Results from AHA Research on COVID-19. Presented at: American Heart Association Scientific Sessions; Nov. 13-15, 2021 (virtual meeting).
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