Citation Information :
Daga MK, Krishna A, Jagiasi BG, Barthakur HS, Jha H, Aladakatti R, Shetty RM, Yadav R, Garg S, Nandakumar SM, Munjal M. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021; 25 (11):1280-1285.
Introduction: There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.
Methods: A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for “very important” on Likert-scale questions in the final round.
Results: Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients’ selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5–10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any “red-flag” signs.
Conclusion: The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5–10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239–1242. DOI: 10.1001/jama.2020.2648.
Rochwerg B, Siemieniuk RA, Agoritsas T, Lamontagne F, Askie L, Lytvyn L, et al. A living WHO guideline on drugs for covid-19. BMJ 2020;370:m3379. DOI: 10.1136/bmj.m3379.
Chang R, Elhusseiny KM, Yeh YC, Sun WZ. COVID-19 ICU and mechanical ventilation patient characteristics and outcomes – a systematic review and meta-analysis. PLoS One 2021;16:e0246318. DOI: 10.1371/journal.pone.0246318.
Parasher A. COVID-19: current understanding of its pathophysiology, clinical presentation and treatment. Postgrad Med J 2020:postgradmedj-2020-138577. DOI: 10.1136/postgradmedj-2020-138577.
Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, et al. Association between administration of systemic corticosteroids and mortality among critically ill patients with COVID-19: a meta-analysis. JAMA 2020;324:1330–1341. DOI: 10.1001/jama.2020.17023.
Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. Dexamethasone in hospitalized patients with covid-19. N Engl J Med 2021;384:693–704. DOI: 10.1056/NEJMoa2021436.
Nasa P, Azoulay E, Khanna AK, Jain R, Gupta S, Javeri Y, et al. Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. Crit Care 2021;25(1):106. DOI: 10.1186/s13054-021-03491-y.
Yang Z, Liu J, Zhou Y, Zhao X, Zhao Q, Liu J. The effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis. J Infect 2020;81:e13–e20. DOI: 10.1016/j.jinf.2020.03.062.
van Paassen J, Vos JS, Hoekstra EM, Neumann KMI, Boot PC, Arbous SM. Corticosteroid use in COVID-19 patients: a systematic review and meta-analysis on clinical outcomes. Crit Care 2020;24:696. DOI: 10.1186/s13054-020-03400-9.
Spagnuolo V, Guffanti M, Galli L, Poli A, Querini PR, Ripa M, et al. Viral clearance after early corticosteroid treatment in patients with moderate or severe covid-19. Sci Rep 2020;10(1):21291. DOI: 10.1038/s41598-020-78039-1.
Kumar A, Arora A, Sharma P, Anikhindi SA, Bansal N, Singla V, et al. Is diabetes mellitus associated with mortality and severity of COVID- 19? A meta-analysis. Diabetes Metab Syndr 2020;14(4):535–545. DOI: 10.1016/j.dsx.2020.04.044.
Juneja D, Jain R, Singh O. Practice pattern of critical care physicians in india for use of corticosteroids in COVID-19 [Internet]. Available from: https://www.japi.org/x284b444/practice-pattern-of-critical-care-physicians-in-india-for-use-of-corticosteroids-in-covid-19.
Cohen PA, Hall LE, John JN, Rapoport AB. The early natural history of SARS-CoV-2 infection: clinical observations from an urban, ambulatory COVID-19 clinic. Mayo Clin Proc 2020;95(6):1124–1126. DOI: 10.1016/j.mayocp.2020.04.010.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475–481. DOI: 10.1016/S2213-2600(20)30079-5.
Chidambaram V, Tun NL, Haque WZ, Majella MG, Sivakumar RK, Kumar A, et al. Factors associated with disease severity and mortality among patients with COVID-19: a systematic review and meta-analysis. PLoS One 2020;15:e0241541. DOI: 10.1371/journal.pone.0241541.
Pandit R, Vaity C, Mulakavalupil B, Matthew A, Sabnis K, Joshi S. Unmasking hypoxia in COVID 19 – six minute walk test. J Assoc Physicians India 2020;68:50–51. PMID: 32798345
Mantha S, Tripuraneni SL, Roizen MF, Fleisher LA. Proposed modifications in the 6-minute walk test for potential application in patients with mild COVID-19: a step to optimize triage guidelines. Anesth Analg 2020;131:398–402. DOI: 10.1213/ANE.0000000000004986.