Corticosteroid uptake rapid for patients hospitalized with COVID-19 following trial data

Key takeaways:

• After the release of results from the RECOVERY COVID-19 trial, corticosteroid use in hospitals went up.
• Reduced mortality was linked to the quick adoption of corticosteroids.

Following the publication of trial data, corticosteroid administration for patients with severe COVID-19 surged in hospitals, according to study results published in Annals of the American Thoracic Society.

“We found that the uptake of corticosteroid use was rapid and associated with a significant, immediate decline in mortality among critically ill patients with COVID-19 in the United States,” Christopher Kearney, MD, MPH, of the Boston University School of Medicine, and colleagues wrote.

In a difference-in-differences analysis, Kearney and colleagues analyzed 34,362 adults (median age, 65 years; 40% women; 54% requiring invasive mechanical ventilation) in the ICU with COVID-19 from the 2020 Premier Healthcare Database to observe how findings from the RECOVERY trial impacted corticosteroid usage and outcomes in this patient population.

As Healio previously reported, early results from the RECOVERY trial showed that low-dose dexamethasone reduced the risk for death by one-third in ventilated patients with COVID-19. There were no major changes to this data in the final paper.

In this analysis, researchers determined whether patients received dexamethasone or non-dexamethasone corticosteroids when admitted and then divided the total cohort according to when the RECOVERY trial results came out relative to their admission date: pre-RECOVERY (March to May 2020) or post-RECOVERY (July to September 2020).

This category of analysis allowed researchers to assess the difference in hospital mortality that was related to the use of findings from the RECOVERY trial. Researchers found this change in mortality by comparing the difference in corticosteroid uptake in two groups of hospitalized patients — those with low corticosteroid use prior to the trial (lowest quartile) and those with high corticosteroid use prior to the trial (highest quartile) — during the period before the release of RECOVERY data vs. the period after the data release.

In the time period after publication of trial findings, researchers observed an increase in patients who received corticosteroids compared with the time before knowledge of the results (21,648 [94%] patients vs. 3,629 [42%] patients) and an increase in those who specifically received dexamethasone (20,073 [87%] patients vs. 401 [5%] patients).

According to researchers, patients admitted after the release of RECOVERY showed a higher median proportion of patients per hospital treated with corticosteroids than those admitted before the release of the trial (95%; interquartile range [IQR], 91%-97% vs. 35%; IQR, 19%-53%).

To conduct difference-in-differences analysis, researchers looked at 3,395 adults from this total cohort and split them up according to the quartile of corticosteroid use in their hospital prior to the trial: lowest quartile (n = 1,530 patients) and highest quartile (n = 1,865).

With the release of the trial results, corticosteroid uptake went from 9% to 94% in patients from the lowest quartile. This increase in corticosteroid use also corresponded to lowered mortality (pre-RECOVERY: 36% vs. post-RECOVERY: 32%), according to researchers.

For those from the highest quartile, researchers found another rise in corticosteroid use after the RECOVERY trial from 75% to 93% but did not see a decrease in mortality (pre-RECOVERY: 30% vs. post-RECOVERY: 34%).

Despite this increase in mortality, dexamethasone use following the release of trial results was estimated to have an 8% (95% CI, –1% to –16%) absolute decrease in mortality, according to researchers.

“These results provide further supportive evidence of the effectiveness of dexamethasone outside of the clinical trial setting and evidence that clinical trial results can be rapidly and effectively adopted with population-level benefit,” Kearney and colleagues wrote. “Future studies should examine details of the implementation process across hospitals after RECOVERY to inform the rapid implementation of future evidence-based therapies.”