September 5, 2020

Background: Over the past few years, corticosteroids have gained traction in the treatment of patients with ARDS and septic shock.  Trials such as APROCCHSS and ADRENAL have shown that the use of corticosteroids is associated with more rapid resolution of shock, weaning from mechanical ventilation in septic shock, and, potentially lower mortality. The RECOVERY trial, the largest RCT to date on the use of corticosteroids in COVID-19, showed treatment with dexamethasone (6mg/d for 10 days)  had an absolute mortality reduction of 11% in patients receiving mechanical ventilation   (IMV) (NNT = 9), 3.5% decreased mortality in patients requiring O2 but not IMV (NNT = 29) and an overall mortality reduction 3% (NNT = 3) compared to usual care alone.  However, there was a signal toward harm (not statistically significant) in patients not receiving respiratory support. In the September 2020 issue of JAMA, there were 3 RCTs (REMAP-CAP, CoDEX, & CAPE COVID) assessing corticosteroid therapy in critically ill patients with COVID-19, as well as a prospective meta-analysis. All 3 RCTs halted enrollment in June 2020 after the RECOVERY trial press release.  The prospective meta-analysis from the WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) working group pooled data from 7 trials (RECOVERY, REMAP-CAP, CoDEX, CAPE COVID, and 3 additional trials) with roughly 1700 patients. In this post we will review the REMAP-CAP, CoDEX, and CAPE COVID trials, as well as the prospective meta-analysis.

June 23, 2020

Background: We have been in need of a sign of hope in the fight against SARS-CoV-2 as it runs from city to city overwhelming health systems.  The majority of patients will be either asymptomatic or have only mild disease.  These patients will improve for the most part with symptomatic care.  There is a smaller portion of patients admitted to the hospital and ICU requiring oxygen therapy or invasive mechanical ventilation (IMV).  In this group of patients, there has not been much promise in the way of treatments improving mortality.  Patients requiring oxygen therapy (HFNC, NIV, IMV, ECMO) are mostly in the pulmonary and hyperinflammatory stage of disease (see below figure). One theoretical option in this hyperinflammatory stage of disease is corticosteroids to help quell the immune response and potentially improve mortality outcomes.

July 24, 2017

Background: Sore throat is a common presentation to the emergency department as well as primary care clinics.  Corticosteroids inhibit transcription of pro-inflammatory mediators in airway endothelial cells responsible for pharyngeal inflammation and symptoms of pain.  They have been used in other upper respiratory tract infections such as acute sinusitis and croup.  In adults, previous studies with dexamethasone are in combination with antibiotics but studies of children have included dexamethasone without antibiotics.  This study is unique as it is evaluating the benefits of oral corticosteroids for acute sore throat in primary care in the absence of antibiotics

August 11, 2016

Background: Acute asthma presentations account for more than 2.1 million Emergency Department (ED) visits annually. In the US, 8.4% of the population is affected by the disease. Current guidelines from the National Heart, Lung, and Blood Institute recommend a minimum of 5 days of oral prednisone to treat moderate to severe asthma exacerbations (NHLBI Guidelines 2007). Oral and parenteral dexamethasone have similar bioavailability, with a duration of action of 72 hours. There has been promising data on dexamethasone for acute asthma from the pediatric literature, as well as a 2-dose regimen in adults. However, due to the strong association with low patient adherence and poor outcomes, a single dose of a long acting oral medication in the ED may help prevent relapse of symptoms.

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