Chest. 2020 Dec 11:S0012-3692(20)35352-6. doi: 10.1016/j.chest.2020.11.050. Online ahead of print.
BACKGROUND: Corticosteroid therapy is commonly used in patients with coronavirus disease 2019 (COVID-19), while its impact on outcomes and which patients could benefit from corticosteroid therapy are uncertain.
RESEARCH QUESTION: Whether clinical phenotypes of COVID-19 were associated with differential response to corticosteroid therapy.
STUDY DESIGN AND METHODS: Critically ill patients with COVID-19 from Tongji hospital between Jan 2020 and Feb 2020 were included, and the main exposure of interest was the administration of intravenous corticosteroids. The primary outcome was 28-day mortality. Marginal structural modeling was used to account for baseline and time-dependent confounders. An unsupervised machine learning approach was carried out to identify phenotypes of COVID-19.
RESULTS: A total of 428 patients were included, and 280/428 (65.4%) patients received corticosteroid therapy. The 28-day mortality was significantly higher in patients who received corticosteroid therapy than in those who did not (53.9% vs. 19.6%; p<0.0001). After marginal structural modeling, corticosteroid therapy was not significantly associated with 28-day mortality (HR 0.80, 95% CI 0.54-1.18; p=0.26). Our analysis identified two phenotypes of COVID-19, and compared to the hypoinflammatory phenotype, the hyperinflammatory phenotype was characterized by elevated levels of proinflammatory cytokines, higher SOFA scores and higher rates of complications. Corticosteroid therapy was associated with a reduced 28-day mortality (HR 0.45; 95% CI 0.25-0.80; p=0.0062) in patients with hyperinflammatory phenotype.
INTERPRETATION: For critically ill patients with COVID-19, corticosteroid therapy was not associated with 28-day mortality, but the use of corticosteroids showed significant survival benefits in patients with the hyperinflammatory phenotype.