Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
J Intensive Care Med. 2023 Nov;38(11):1003-1014. doi: 10.1177/08850666231177200. Epub 2023 May 24.
Although corticosteroids have become the standard of care for patients with coronavirus disease-2019 (COVID-19) on supplemental oxygen, there is growing evidence of differential treatment response. This study aimed to evaluate if there was an association between biomarker-concordant corticosteroid treatment and COVID-19 outcomes.
This registry-based cohort study included adult COVID-19 hospitalized patients between January 2020 and December 2021 from 109 institutions. Patients with available C-reactive protein (CRP) levels within 48 h of admission were evaluated. Those on steroids before admission, stayed in the hospital for <48 h, or were not on oxygen support were excluded. Corticosteroid treatment was biomarker-concordant if given with high baseline CRP ≥150 mg/L or withheld with low CRP (<150 mg/L) and vice-versa was considered discordant (low CRP with steroids, high CRP without steroids). Hospital mortality was the primary outcome. Sensitivity analyses were conducted using varying CRP level thresholds. The model interaction was tested to determine steroid effectiveness with increasing CRP levels.
Corticosteroid treatment was biomarker-concordant in 1778 (49%) patients and discordant in 1835 (51%). The concordant group consisted of higher-risk patients than the discordant group. After adjusting for covariates, the odds of in-hospital mortality were significantly lower in the concordant group than the discordant (odds ratio [95% confidence interval (C.I.)] = 0.71 [0.51, 0.98]). Similarly, adjusted mortality difference was significant at the CRP thresholds of 100 and 200 mg/L (odds ratio [95% C.I.] = 0.70 [0.52, 0.95] and 0.57 [0.38, 0.85], respectively), and concordant steroid use was associated with lower need for invasive ventilation for 200 mg/L threshold (odds ratio [95% C.I.] = 0.52 [0.30, 0.91]). In contrast, no outcome benefit was observed at CRP threshold of 50. When the model interaction was tested, steroids were more effective at reducing mortality as CRP levels increased.
Biomarker-concordant corticosteroid treatment was associated with lower odds of in-hospital mortality in severe COVID-19.
尽管皮质类固醇已成为 COVID-19 患者补充氧气治疗的标准治疗方法，但越来越多的证据表明存在不同的治疗反应。本研究旨在评估生物标志物一致的皮质类固醇治疗与 COVID-19 结局之间是否存在关联。
本基于登记的队列研究纳入了 2020 年 1 月至 2021 年 12 月期间来自 109 个机构的 COVID-19 住院成年患者。评估了入院后 48 小时内 C-反应蛋白（CRP）水平可获得的患者。排除了入院前使用类固醇、住院时间<48 小时或未接受氧气支持的患者。如果给予高基线 CRP≥150mg/L，则皮质类固醇治疗为生物标志物一致；如果给予低 CRP（<150mg/L）则不予治疗，反之亦然，则认为治疗不一致（低 CRP 时用类固醇，高 CRP 时不用类固醇）。住院死亡率为主要结局。使用不同的 CRP 水平阈值进行了敏感性分析。测试了模型交互作用，以确定随着 CRP 水平的升高，类固醇的有效性。
1778 名（49%）患者的皮质类固醇治疗为生物标志物一致，1835 名（51%）患者为不一致。一致组的患者比不一致组的患者风险更高。在调整了协变量后，与不一致组相比，一致组的住院死亡率显著降低（优势比[95%置信区间（CI）]为 0.71[0.51,0.98]）。同样，在 CRP 阈值为 100 和 200mg/L 时，调整后的死亡率差异具有统计学意义（优势比[95%CI]为 0.70[0.52,0.95]和 0.57[0.38,0.85]），且一致使用类固醇与 200mg/L 阈值的侵入性通气需求降低相关（优势比[95%CI]为 0.52[0.30,0.91]）。相比之下，在 CRP 阈值为 50 时，未观察到获益。当测试模型交互作用时，随着 CRP 水平的升高，类固醇降低死亡率的效果更显著。
严重 COVID-19 患者中，生物标志物一致的皮质类固醇治疗与较低的住院死亡率相关。
