The pandemic of COVID-19 in 2020 has brought serious threats to the public around the world. As of April 24 2020, the crude global case fatality rate was around 7% and largely variated from different countries . So far, there are still no specific antiviral treatments for COVID-19 pneumonia. It becomes crucial issues for scientists to improve the cure rate, shorten the course of the severe type, and reduce the mortality caused by SARS-CoV-2 virus.
In our study, we retrospectively evaluated the benefit and harm on the use of glucocorticoids in patients with severe COVID-19. A total of 18 patients with severe COVID-19 pneumonia were treated with glucocorticoids. The courses of glucocorticoids therapy for patients were different according to their clinical conditions, which ranged from 4 to 30 days with a median course of 17 days. No severe adverse effects were observed. Six patients (33.3%) presented mild adverse effects, including diarrhea, gastrointestinal bleeding and insomnia. Those symptoms were relived after adjusting the dosage and expectant treatment. Adverse effects associated with long-term glucocorticoids use are not considered relevant for this study, because of the short duration and low dose of the glucocorticoids prescribed.
The outcomes of our patients were generally satisfied. Sixteen patients had absorption of pulmonary infections. Fifteen patients could respire without oxygen supply. All the patients had three times of RT-PCR test for SARS-CoV-2 after treatment and all patients were negative for the last time results. Five cases discharged according to clinically standard of the guideline. Twelve cases who were in a stable condition for treatment remained in hospital. One case was still in critical condition.
The use of corticosteroid remains controversial in treatment of respiratory infections and there is no conclusive evidence suggesting the balance of benefit and harms in treatment of COVID-19 pneumonia. Among severe patients with virus infection, the overwhelming inflammation and cytokine-related lung injury might cause rapidly progressive pneumonia, even fatal outcomes . Corticosteroid has been widely used in clinic to decrease the inflammatory responses in lungs, prevent acute lung injury and avoid ARDS. However, the clinical guidelines of WHO  and the US  suggest against the routine corticosteroid therapy in patients with COVID-19 due to the concerns of adverse effects. A systematic review and meta-analysis from 15 studies showed that corticosteroid was associated with increased mortality, longer length of hospital stay and higher risk of secondary infections in critical patients with coronavirus infection . However, the meta-analysis may be limited to enroll retrospective studies, remain controlling for the time and dosage of corticosteroid and a potential publication bias. In a prospective cohort study on hospitalization of influenza A (H1N1)pdm09, low-to-moderate dose corticosteroids (25–150 mg/d) was associated with reduced mortality among patients with PaO2/FiO2 < 300 mmHg, while the relationship was not observed in high dose group (> 150 mg/d). The evidence also did not support the benefit of corticosteroid among mild patients (PaO2/FiO2 > 300 mmHg) . Another RCT also supported the early, low-dose (0.5 mg/kg/d) and short-term (5 or 7 days) use of corticosteroid therapy reduced the risk of treatment failure among patients with severe community-acquired pneumonia .
Our study added some evidence to precautiously consider the early use of low dose glucocorticoids to prevent fatal outcomes for severe patients with COVID-19. This is accordance with current limited evidence. A previous report with 15 severe COVID-19 patients suggested the early systematic corticosteroids therapy among could enhance SaO2 and PaO2/FiO2, and no evidence support the improvement on deaths due to the small sample size . Another retrospective study with 11 of 31 patients received corticosteroid treatment reported that corticosteroid did no increase virus clearance time and length of hospital stay in patients with mild COVID-19 . Nevertheless, corticosteroid therapy still requires carefully considering the patients’ clinical conditions, time, dose, and duration of treatment. A well-designed large scale RCT is also warranted to further evaluate the efficacy of corticosteroid.
Our study has a few limitations. First, glucocorticoids treatments in our hospital were only applied for severe patients. Evidence from a small sample size with 18 patients might not be conclusive. Second, this was an observational study. We were not able to set up a referent group to compare the effect of glucocorticoids treatment. Confounding factors might not be eliminated. The delay of virus clearance, shorten of clinical courses and effect of reducing ARDS remained further investigation. Lastly, we only investigated the short-term effect of glucocorticoids treatments, a longer follow-up period is warranted for evaluate the long-term benefit in the future.
In summary, early appropriate use of glucocorticoids may benefit for patients with severe COVID-19 pneumonia. We did not observe adverse effects on the negative transformation of nucleic acid detection of COVID-19.