RECOVERY RCT – High or Low Dose Dexamethasone for COVID-19?

June 19, 2023

Written by Christian Gerhart

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In this large, randomized controlled trial, hypoxic patients requiring simple or no oxygen who received higher dose dexamethasone (20mg for 5 days, then 10mg for 5 days) had a higher mortality compared to patients who received usual care, most of whom were treated with 6mg per day of dexamethasone for 10 days.

Why does this matter?
For a while, COVID was everywhere and we ordered COVID tests on everyone. Although it isn’t as bad now, many patients still require hospitalization or aggressive respiratory support. It is important that we continue to stay up to date on COVID treatments.

Usual dose steroids are superior
This RECOVERY group study, which included COVID patients in the United Kingdom, South and Southeast Asia, as well as Africa, was a randomized controlled trial of 1,272 patients with clinically suspected (5%) or laboratory diagnosed (95%) COVID-19 who were hypoxic and received either no oxygen (1%) or simple oxygen (99%). Patients were randomized to either usual care or a higher dose steroid treatment group and were compared using an intention-to-treat analysis. Patients requiring non-invasive ventilation or mechanical ventilation at the time of randomization were excluded. In the usual care group, 87% of patients were treated with 6mg of dexamethasone for 10 days or until discharge. In the higher dose steroid treatment group, 91% of patients randomized received higher dose steroids, which was defined as dexamethasone (either oral or IV) 20mg daily for 5 days followed by 10mg daily for 5 days or until discharge.

Patients who were treated with higher dose steroids had a higher 28-day mortality compared to usual care (19% vs. 12%) with a RR of 1.59 (95%CI 1.2-2.1, p=0.0012). Patients in the higher dose steroid group also had a higher rate of progression to any ventilatory support (18% vs. 14%, RR 1.3) and of non-COVID-19 pneumonia (10% vs. 6%). Of note, the trial was stopped early due to the signal of harm in the higher dose steroid group. This study provides solid evidence that we should continue treating hypoxic COVID-19 patients with the usual 6mg per day of dexamethasone.

Editor’s note: The study occurred from May 2021 to May 2022, during which the Delta variant was predominant, with Omicron surging at the tail end. Also, only half the patients enrolled were vaccinated during this trial, which impacts the generalizability of this study. ~Clay Smith

Source
Higher dose corticosteroids in patients admitted to hospital with COVID-19 who are hypoxic but not requiring ventilatory support (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet. 2023 May 6;401(10387):1499-1507. doi: 10.1016/S0140-6736(23)00510-X. Epub 2023 Apr 13.