The Uncertain Role of Corticosteroids in the Treatment of COVID-19—Reply

In Reply In response to the concerns about survival bias and the findings regarding methylprednisolone in our Original Investigation,¹ we treated methylprednisolone use as a time-dependent variable with the Cox model in the same subgroup of 84 patients. The hazard ratio of methylprednisolone use for death was 0.52 (95% CI, 0.27-1.02; P = .06), suggesting a trend toward a lower mortality.

Similarly, Ellsworth et al indicated that there was no difference in mortality between patients with acute respiratory distress syndrome who received methylprednisolone (23 of 50 [46%]) and those who did not (21 of 34 [62%]; 95% CI, –40% to 8%; P = .23). There was a trend toward a better outcome, and the nonsignificant P value might indicate that this subgroup analysis was underpowered. We followed up with patients to hospital discharge or death. We agree that the follow-up might be substantially shorter than needed to observe steroid adverse effects. As we discussed,¹ the findings in our cohort study should be interpreted with caution because of potential bias, residual confounding, and the small sample size.

The role of corticosteroids in treating acute respiratory distress syndrome remains controversial and inconclusive.² For patients with coronavirus disease 2019 (COVID-19), there are insufficient data to recommend for or against the use of systemic corticosteroids.³ Although our findings about methylprednisolone use contribute to the evidence base for the systemic corticosteroids in patients with COVID-19 and acute respiratory distress syndrome, well-designed double-blinded randomized clinical trials are needed.

Corresponding Author: Yuanlin Song, MD, Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai 200032, China (ylsong70_02@163.com).

Published Online: August 3, 2020. doi:10.1001/jamainternmed.2020.2435

Conflict of Interest Disclosures: None reported.