VA Puget Sound Health Care System, Seattle, WA, USA
Dept of Medicine, University of Washington, Seattle, WA, USA.
Eur Respir J. 2022 Jul 13;60(1). doi: 10.1183/13993003.02532-2021. Print 2022 Jul.
Dexamethasone decreases mortality in coronavirus disease 2019 (COVID-19) patients on intensive respiratory support (IRS) but is of uncertain benefit if less severely ill. We determined whether early (within 48 h) dexamethasone was associated with mortality in patients hospitalised with COVID-19 not on IRS.
We included patients admitted to US Veterans Affairs hospitals between 7 June 2020 and 31 May 2021 within 14 days after a positive test for severe acute respiratory syndrome coronavirus 2. Exclusions included recent prior corticosteroids and IRS within 48 h. We used inverse probability of treatment weighting (IPTW) to balance exposed and unexposed groups, and Cox proportional hazards models to determine 90-day all-cause mortality.
Of 19 973 total patients (95% men, median age 71 years, 27% black), 15 404 (77%) were without IRS within 48 h. Of these, 3514 out of 9450 (34%) patients on no oxygen received dexamethasone and 1042 (11%) died; 4472 out of 5954 (75%) patients on low-flow nasal cannula (NC) only received dexamethasone and 857 (14%) died. In IPTW stratified models, patients on no oxygen who received dexamethasone experienced 76% increased risk for 90-day mortality (hazard ratio (HR) 1.76, 95% CI 1.47-2.12); there was no association with mortality among patients on NC only (HR 1.08, 95% CI 0.86-1.36).
In patients hospitalised with COVID-19, early initiation of dexamethasone was common and was associated with no mortality benefit among those on no oxygen or NC only in the first 48 h; instead, we found evidence of potential harm. These real-world findings do not support the use of early dexamethasone in hospitalised COVID-19 patients without IRS.
地塞米松可降低接受重症呼吸支持（IRS）的 2019 冠状病毒病（COVID-19）患者的死亡率，但对于病情较轻的患者，其益处尚不确定。我们确定了在 COVID-19 住院患者中，IRS 应用不足的情况下，早期（48 小时内）使用地塞米松是否与死亡率相关。
我们纳入了 2020 年 6 月 7 日至 2021 年 5 月 31 日期间，美国退伍军人事务部医院内住院的 COVID-19 患者，这些患者在 SARS-CoV-2 检测阳性后 14 天内入院。排除标准包括最近使用皮质类固醇和 48 小时内 IRS。我们使用逆概率治疗加权（IPTW）来平衡暴露组和未暴露组，并用 Cox 比例风险模型来确定 90 天全因死亡率。
在 19973 名患者中（95%为男性，中位年龄 71 岁，27%为黑人），有 15404 名（77%）在 48 小时内没有 IRS。其中，9450 名未吸氧患者中有 3514 名（34%）接受了地塞米松治疗，1042 名（11%）死亡；5954 名仅接受低流量鼻导管（NC）吸氧的患者中有 4472 名（75%）接受了地塞米松治疗，857 名（14%）死亡。在 IPTW 分层模型中，接受地塞米松治疗的未吸氧患者 90 天死亡率增加了 76%（风险比[HR] 1.76，95%置信区间 1.47-2.12）；而仅接受 NC 治疗的患者与死亡率无关（HR 1.08，95%置信区间 0.86-1.36）。
在 COVID-19 住院患者中，早期应用地塞米松很常见，但在 48 小时内没有 IRS 的患者中，地塞米松对接受 NC 或不吸氧的患者无生存获益；相反，我们发现了潜在危害的证据。这些真实世界的数据不支持在没有 IRS 的 COVID-19 住院患者中早期使用地塞米松。
