Department of Pharmacy, NYU Langone Health, New York, NY, USA.
Division of Pulmonary Critical Care, NYU Langone Health, New York, NY, USA.
Ann Pharmacother. 2023 Jan;57(1):5-15. doi: 10.1177/10600280221094571. Epub 2022 May 19.
Corticosteroids and tocilizumab have been shown to improve survival in patients who require supplemental oxygen from coronavirus disease 2019 (COVID-19) pneumonia. The optimal dose of immunosuppression for the treatment of COVID-19 acute respiratory distress syndrome (ARDS) is still unknown.
The objective of this study was to evaluate the effectiveness and safety of high- versus low-dose corticosteroids with or without tocilizumab for the treatment of COVID-19 ARDS.
This was a retrospective study of patients admitted to the intensive care unit (ICU) requiring mechanical ventilation who received high- versus low-dose corticosteroids with or without tocilizumab. The primary outcome was survival to discharge. Safety outcomes included infections and incidence of hyperglycemia.
In this cohort, 110 (54%) and 95 (46%) patients received high-dose (≥10 mg dexamethasone equivalent) and low-dose (<10 mg dexamethasone equivalent) corticosteroids for more than 3 consecutive days, respectively. Thirty-five patients (32%) in the high-dose group and 33 patients (35%) in the low-dose group survived to hospital discharge ( = 0.85). There was no difference in 28-day mortality in patients who received high-dose corticosteroids without tocilizumab compared with those who received low-dose corticosteroids with tocilizumab (n = 38/82, 46% vs n = 19/40, 48% = 0.99); however, there was a higher mortality if patients received low-dose corticosteroids without tocilizumab (n = 39/55, 71%, = 0.01). The highest rate of a bacterial pneumonia was in patients who received high-dose corticosteroids with tocilizumab.
In critically ill patients with COVID-19 ARDS requiring mechanical ventilation, we found no difference in high- versus low-dose corticosteroids with regard to survival to hospital discharge. However, patients receiving only low-dose corticosteroids without tocilizumab did worse than the other groups. Larger prospective studies are needed to determine the optimal immunosuppression dosing strategy in this patient population.
皮质类固醇和托珠单抗已被证明可提高因 2019 年冠状病毒病（COVID-19）肺炎需要补充氧气的患者的生存率。用于治疗 COVID-19 急性呼吸窘迫综合征（ARDS）的最佳免疫抑制剂量仍不清楚。
本研究旨在评估高剂量与低剂量皮质类固醇联合或不联合托珠单抗治疗 COVID-19 ARDS 的疗效和安全性。
这是一项回顾性研究，纳入了入住重症监护病房（ICU）并需要机械通气的患者，这些患者接受了高剂量与低剂量皮质类固醇联合或不联合托珠单抗治疗。主要结局为出院时的生存率。安全性结局包括感染和高血糖发生率。
在该队列中，分别有 110 例（54%）和 95 例（46%）患者接受了超过 3 天的高剂量（≥10mg 地塞米松等效物）和低剂量（<10mg 地塞米松等效物）皮质类固醇治疗。高剂量组中有 35 例（32%）和低剂量组中有 33 例（35%）患者存活至出院（=0.85）。未接受托珠单抗的高剂量皮质类固醇组与接受托珠单抗的低剂量皮质类固醇组患者的 28 天死亡率无差异（n=38/82，46%vs n=19/40，48%=0.99）；然而，如果患者未接受托珠单抗的低剂量皮质类固醇治疗，死亡率更高（n=39/55，71%，=0.01）。接受高剂量皮质类固醇和托珠单抗治疗的患者中，细菌性肺炎发生率最高。
在需要机械通气的 COVID-19 ARDS 危重症患者中，我们发现高剂量与低剂量皮质类固醇在出院生存率方面没有差异。然而，仅接受低剂量皮质类固醇且未接受托珠单抗治疗的患者预后比其他组更差。需要更大规模的前瞻性研究来确定该患者人群的最佳免疫抑制剂量策略。
