Dexamethasone use tied to lower mortality odds in hospitalized COVID-19 patients with mechanical ventilation: JAMA

The national multicenter cohort study involving inpatients with COVID-19 revealed that early dexamethasone administration was linked with improved mortality or discharge to hospice in those needing supplemental oxygen or mechanical ventilation (MV) and extracorporeal membrane oxygenation but not in those who did not require supplemental oxygen or noninvasive positive pressure ventilation (NIPPV).

In hospitalized patients with COVID-19, not many effective therapeutics are available despite millions of deaths globally from COVID-19 and thousands of trials exploring novel and repurposed drugs. Observational studies and clinical trials have shown varying effects of systemic corticosteroids, including dexamethasone, in this population, with limited descriptions of important patient subgroups. To fill this knowledge gap, Ahmad Mourad, Duke University Medical Center, Durham, North Carolina, and colleagues aimed to examine the dexamethasone's clinical use for hospitalized patients with COVID-19 respiratory illness and to explore the heterogeneity of treatment outcomes across different subgroups.

For this purpose, they performed a retrospective, propensity score–weighted cohort study involving adult patients hospitalized for at least 48 hours for COVID-19 respiratory illness between 2020 and 2021 across 156 hospitals across the US.

They were exposed to systemic administration of dexamethasone within 48 hours of either admission or escalation in oxygen support. The study's primary outcome was all-cause in-hospital mortality or discharge to hospice.

The authors reported the following findings:

• The authors identified 80 699 patients who met the eligibility criteria (median age, 64 years; 46.6% were women). Of these patients, 16.2% did not require supplemental oxygen within 48 hours of admission, 69.8% required supplemental oxygen, 9.4% required noninvasive positive pressure ventilation (NIPPV), and 4.6% required mechanical ventilation and ECMO.
• After adjustment by propensity score overlap weighting, early dexamethasone use was associated with a reduction in a composite outcome of in-hospital mortality or discharge to hospice for patients receiving supplemental oxygen (aOR, 0.92) and MV and ECMO (aOR, 0.82).
• All-cause inpatient mortality or discharge to hospice was not lower for patients who received dexamethasone in the no supplemental oxygen group (aOR, 0.90) and the NIPPV group (aOR, 0.87).
• Patients with more comorbidities had more significant benefit from dexamethasone use.

"In our large national cohort study of patients with COVID-19 respiratory illness hospitalized between 2020 and 2021, early dexamethasone administration was associated with improved discharge to hospice or mortality in those requiring supplemental oxygen or MV and ECMO," the researchers wrote. "Continued exploration of patient subgroups will help inform and individualize treatment for COVID-19."

"Overall, these results show that despite the overtime evolution of the COVID-19 pandemic, dexamethasone remains beneficial for these hospitalized patients in a clinical practice setting," they conclude.

Reference:

Mourad A, Thibault D, Holland TL, et al. Dexamethasone for Inpatients With COVID-19 in a National Cohort. JAMA Netw Open. 2023;6(4):e238516. doi:10.1001/jamanetworkopen.2023.8516