In a demonstration of global collaboration, clinician-scientists have pooled data from 121 hospitals in 8 countries to find that inexpensive, widely available steroids may improve the odds that very sick patients with COVID-19 will survive the illness. The findings were made through the Randomized Embedded Multifactorial Adaptive Platform-Community Acquired Pneumonia (REMAP-CAP) trial and reported in JAMA.1 The World Health Organization is updating its COVID-19 treatment guidance as a result.
REMAP-CAP is one of seven randomized control trials to test corticosteroids for treating COVID-19 in critically ill patients. An analysis combining all the trial data reinforces the June results of the UK RECOVERY trial, which found the steroid dexamethasone reduced deaths by 29% in ventilated patients with COVID-19.2
Derek Angus, MD, MPH
“It is relatively rare in medicine that you find drugs where the evidence of their effectiveness in saving lives is so consistent,” said lead author Derek Angus, MD, MPH, Professor and Chair of the Department of Critical Care Medicine at the University of Pittsburgh and Chief Health Care Innovation Officer at the University of Pittsburgh Medical Center. “This is, in many respects, the single clearest answer we’ve had so far on how to manage very ill COVID-19 patients. People on ventilators or oxygen and under intensive care should definitely be given corticosteroids.”
Between March and June, the REMAP-CAP corticosteroid trial randomly assigned 403 adult patients with COVID-19 admitted to an intensive care unit to receive the steroid hydrocortisone or no steroids at all. The trial found a 93% probability that giving patients a 7-day intravenous course of hydrocortisone would result in better outcomes than not giving the steroid. The results were consistent across age, race, and sex.
“This is, in many respects, the single clearest answer we’ve had so far on how to manage very ill COVID-19 patients.”— Derek Angus, MD, MPH
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REMAP-CAP and the other corticosteroid trials did not test the drugs in patients with less severe COVID-19. Steroids are not currently recommended for these patients because they can dampen the immune system and have serious side effects. Further, the REMAP-CAP study was mostly conducted in resource-rich countries across Europe, North America, and Australasia, so the findings may not translate to low- and middle-income countries.
Because it is designed to simultaneously test multiple combinations of potential therapies—as opposed to the traditional, slow clinical trial process that tests one therapy at a time—REMAP-CAP is particularly well suited for rapidly identifying effective treatments during the COVID-19 pandemic. It currently is testing thousands of different treatment regimens, including various doses and combinations of vitamin C, convalescent plasma, blood thinners, antivirals, and immune modulators.
DISCLOSURE: For full disclosures of the study authors, visit jamanetwork.com.
1. Angus DC, Derde L, Al-Beidh F, et al: 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. September 2, 2020 (early release online).
2. Statement from the chief investigators of the randomised evaluation of COVID-19 therapy (RECOVERY) trial on dexamethasone. Available at https://www.recoverytrial.net/news/low-cost-dexamethasone-reduces-death-by-up-to-one-third-in-hospitalised-patients-with-severe-respiratory-complications-of-covid-19. Accessed September 9, 2020.