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Corticosteroids in COVID-19 ARDSEvidence and Hope During the Pandemic

Educational Objective
To understand how to leverage corticosteroids to manage the COVID-19 pandemic
1 Credit CME

Corticosteroids, such as hydrocortisone and dexamethasone, have anti-inflammatory, antifibrotic, and vasoconstrictive effects, which intensivists have been trying to leverage for decades to improve outcomes in patients with acute respiratory distress syndrome (ARDS) and septic shock. In the first description of ARDS in 1967, Ashbaugh and colleagues noted that “corticosteroids appeared to have value in the treatment of patients with fat-embolism and possibly viral pneumonia.”1

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Article Information

Corresponding Author: Todd W. Rice, MD, MSc, Department of Medicine, Vanderbilt University, T-1218 MCN, Nashville, TN 37232 (todd.rice@vumc.org).

Published Online: September 2, 2020. doi:10.1001/jama.2020.16747

Conflict of Interest Disclosures: Dr Prescott reported she serves on the Surviving Sepsis Campaign Guidelines Panel. Dr Rice reported personal fees from Cumberland Pharmaceuticals and personal fees from Avisa Pharmaceutical outside the submitted work.

Funding/Support: This content is the result of work supported with resources and use of facilities at the Ann Arbor VA Medical Center.

Role of the Funder/Sponsor: The Ann Arbor VA Medical Center had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This article does not represent the views of the Department of Veterans Affairs or the US government.

References
1.
Ashbaugh  DG , Bigelow  DB , Petty  TL , Levine  BE .  Acute respiratory distress in adults.   Lancet. 1967;2(7511):319-323. doi:10.1016/S0140-6736(67)90168-7 PubMedGoogle ScholarCrossref
2.
Bellani  G , Laffey  JG , Pham  T ,  et al; LUNG SAFE Investigators; ESICM Trials Group.  Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.   JAMA. 2016;315(8):788-800. doi:10.1001/jama.2016.0291 PubMedGoogle ScholarCrossref
3.
Annane  D , Renault  A , Brun-Buisson  C ,  et al; CRICS-TRIGGERSEP Network.  Hydrocortisone plus fludrocortisone for adults with septic shock.   N Engl J Med. 2018;378(9):809-818. doi:10.1056/NEJMoa1705716 PubMedGoogle ScholarCrossref
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Venkatesh  B , Finfer  S , Cohen  J ,  et al; ADRENAL Trial Investigators and the Australian–New Zealand Intensive Care Society Clinical Trials Group.  Adjunctive glucocorticoid therapy in patients with septic shock.   N Engl J Med. 2018;378(9):797-808. doi:10.1056/NEJMoa1705835 PubMedGoogle ScholarCrossref
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Villar  J , Ferrando  C , Martínez  D ,  et al; Dexamethasone in ARDS Network.  Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial.   Lancet Respir Med. 2020;8(3):267-276. doi:10.1016/S2213-2600(19)30417-5 PubMedGoogle ScholarCrossref
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Fang  F , Zhang  Y , Tang  J ,  et al.  Association of corticosteroid treatment with outcomes in adult patients with sepsis: a systematic review and meta-analysis.   JAMA Intern Med. 2019;179(2):213-223. doi:10.1001/jamainternmed.2018.5849 PubMedGoogle ScholarCrossref
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Ye  Z , Wang  Y , Colunga-Lozano  LE ,  et al.  Efficacy and safety of corticosteroids in COVID-19 based on evidence for COVID-19, other coronavirus infections, influenza, community-acquired pneumonia and acute respiratory distress syndrome: a systematic review and meta-analysis.   CMAJ. 2020;192(27):E756-E767. doi:10.1503/cmaj.200645 PubMedGoogle ScholarCrossref
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Alhazzani  W , Møller  MH , Arabi  YM ,  et al.  Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19).   Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/CCM.0000000000004363 PubMedGoogle ScholarCrossref
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Bhimraj  A , Morgan  RL , Shumaker  AH ,  et al.  Infectious Diseases Society of America Guidelines on the treatment and management of patients with COVID-19.   Clin Infect Dis. 2020;ciaa478. doi:10.1093/cid/ciaa478 PubMedGoogle Scholar
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Wu  C , Chen  X , Cai  Y ,  et al  Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China.   JAMA Intern Med. 2020;180(7):934-943. doi:10.1001/jamainternmed.2020.0994Google ScholarCrossref
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Lee  N , Allen Chan  KC , Hui  DS ,  et al.  Effects of early corticosteroid treatment on plasma SARS-associated coronavirus RNA concentrations in adult patients.   J Clin Virol. 2004;31(4):304-309. doi:10.1016/j.jcv.2004.07.006 PubMedGoogle ScholarCrossref
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Arabi  YM , Mandourah  Y , Al-Hameed  F ,  et al; Saudi Critical Care Trial Group.  Corticosteroid therapy for critically ill patients with Middle East Respiratory Syndrome.   Am J Respir Crit Care Med. 2018;197(6):757-767. doi:10.1164/rccm.201706-1172OC PubMedGoogle ScholarCrossref
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Horby  P , Lim  WS , Emberson  JR ,  et al; RECOVERY Collaborative Group.  Dexamethasone in hospitalized patients with Covid-19: preliminary report.   N Engl J Med. Published online July 17, 2020.doi:10.1056/NEJMoa2021436PubMedGoogle Scholar
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The Writing Committee for the REMAP-CAP Investigators.  Effect of hydrocortisone on mortality and organ support in patients with severe COVID-19: the REMAP-CAP COVID-19 Corticosteroid Domain randomized clinical trial.   JAMA. Published online September 2, 2020. doi:10.1001/jama.2020.17022Google Scholar
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

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