Antiviral-corticosteroid combo shows potential against COVID-19

The risk of clinical progression, invasive mechanical ventilation, and death among patients with the novel coronavirus disease (COVID-19) may be attenuated by a combination treatment of corticosteroids and antivirals, according to a recent Singapore study.

“The use of prednisolone during early pneumonia in our study [led to] a significantly better outcome, which may be due to the concurrent administration of antiviral agents such as hydroxychloroquine (HCQ) or lopinavir/ritonavir,” the researchers said.

Ninety-four adults with COVID-19 participated in the current retrospective analysis. Fifty-seven received antiviral therapy alone, while the remaining 35 were given adjunctive prednisolone. COVID-19 was confirmed through nasopharyngeal swabs subjected to polymerase chain reaction. All patients received care at the Khoo Tech Puat Hospital in Singapore.

Forty-four patients presented with pneumonia, of whom 68.9 percent did not require supplemental oxygen. At baseline, more patients assigned to receive add-on prednisolone had pneumonia, needed supplemental oxygen, and were on antibiotics. [Open Forum Infect Dis 2020;7:ofaa486]

Seventeen patients eventually saw clinical progression of COVID-19, corresponding to a rate of 18.5 percent relative to the overall sample. This occurred nominally more frequently among patients not on prednisolone, though the difference fell short of significance (22.8 percent vs 11.4 percent; p=0.172). Similarly, the need for invasive ventilation was slightly lower in the prednisolone group.

In terms of survival, one patient in the monotherapy arm died after mechanical ventilation; no such incident was reported in the prednisolone-treated group.

Moreover, levels of C-reactive protein (CRP) dropped following the initiation of prednisolone treatment. In patients treated with antivirals alone, CRP trended upwards 5–8 days after initiation before declining.

Prednisolone showed even greater value in the subsample of patients with pneumonia. Unweighted Kaplan-Meier estimates showed significant suppression of disease progression (58.8 percent vs 11.1 percent; p<0.001) and mechanical ventilation (41.2 percent vs 11.3 percent; p=0.016) among those on adjunctive corticosteroid.

Weighted Cox regression analysis confirmed that prednisolone had a significant protective effect against disease progression both in overall sample (hazard ratio [HR], 0.08, 95 percent confidence interval [CI], 0.01–0.99; p=0.049) and in patients with pneumonia (HR, 0.15, 95 percent CI, 0.06–0.39; p<0.001).

While the findings suggest the potential of corticosteroids against COVID-19, there remains cause for caution, according to the researchers.

“The prominent protective effect of adjunctive prednisolone observed in our cohort with early pneumonia and the varying effect of dexamethasone on different days of illness of COVID-19 in the RECOVERY trial call for different treatment strategies at different clinical stages of COVID-19,” the researchers said.

“Further prospective studies should be considered to evaluate the clinical efficacy of combination treatment in early COVID-19 pneumonia,” they added.