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Does methylprednisolone reduce the mortality risk in hospitalized COVID-19 patients? A meta-analysis of randomized control trials

Hasan SS, Kow CS, Mustafa ZU, Merchant HA

Expert Rev Respir Med, 2021 08;15(8):1049-1055.
PMID: 33945381 DOI: 10.1080/17476348.2021.1925546

Objectives: The question remained if mortality benefits with dexamethasone seen in patients with coronavirus disease 2019 (COVID-19) also extend to other systemic corticosteroids such as methylprednisolone. This article presents a meta-analysis of randomized controlled trials (RCTs) to ascertain if methylprednisolone can be recommended for use in patients with COVID-19 to prevent deaths.Methods: Systematic literature search was performed in PubMed, Scopus, Cochrane Central Register of Controlled Trials, and preprint servers until 13 April 2021. The outcome of interest was all-cause mortality. The random-effects model for the meta-analysis was utilized to estimate the pooled odds ratio (OR) at 95% confidence intervals (CI).Results: Five RCTs were included in the meta-analysis. The pooled OR for all-cause mortality was 0.64 (95% CI: 0.29 - 1.43, n = 652) comparing methylprednisolone with the control, indicating no mortality benefits. A similar finding was noted with a sub-group analysis including four trials that used low-dose methylprednisolone. However, the only trial that administered high dose methylprednisolone indicated a statistically significant mortality benefit (OR 0.08, 95% CI: 0.02-0.42).Conclusions: In determining equipotent doses for an acute short-course pulse therapy of corticosteroids, the biological half-life of steroids should also be accounted for besides the potency factor. A short duration (3-5 days) pulse therapy of high-dose methylprednisolone can be a promising alternative to the low-dose dexamethasone therapy in severely ill patients with COVID-19 to prevent deaths.
COVID-19 first anniversary review of cases, hospitalization, and mortality in the UK

Merchant HA, Kow CS, Hasan SS

Expert Rev Respir Med, 2021 08;15(8):973-978.
PMID: 33573416 DOI: 10.1080/17476348.2021.1890035

Introduction: The first confirmed COVID-19 case in UK dates to 11 January 2020, exhibiting its first peak during April 2020. The country has since been hit by another wave in the winter 2020, almost at the first anniversary of the pandemic.Areas covered: An in-depth analysis of the COVID-19 positive cases in the UK throughout the year, hospitalizations, patients in critical care, and COVID-19 associated deaths.Expert opinion: The COVID-19 associated hospital admission accounts to 15% of total COVID-19 positive cases in November 2020. The percentage of total COVID-19 positive patients in the country died from the disease was under 4% in November 2020. Total deaths in England (all-cause) from June to October 2020 were similar to the historic averages. Age was the single most determinator of COVID-19 associated mortality, 50 years or older accounted for 98% of total COVID deaths. Age distribution of COVID-19 associated deaths in 2020 was similar to all-cause mortality age distribution in 2019. There was no significant improvement in the survival rate of COVID-19 patients receiving critical care. This prompts an urgent need to invest in novel antiviral therapeutics to save the most vulnerable in the society.
Impact of long-term exposure wildfire smog on respiratory health outcomes

Ontawong A, Saokaew S, Jamroendararasame B, Duangjai A

Expert Rev Respir Med, 2020 05;14(5):527-531.
PMID: 32156169 DOI: 10.1080/17476348.2020.1740089

Background: Air pollution is a global problem and also linked to respiratory diseases. Wildfire smog is a major cause of air pollution in the upper northern area of Thailand. Thus, in the current study, we examined whether long-term exposure to wildfire smog induces lung function changes in a population from the upper northern area of Thailand.Methods: The lung function of 115 participants with long-term exposure smog was determined using peak flow meter.Results: Long-term smoke exposure participants decreased FEV1 (forced expiratory volume in 1 second)/FVC (forced vital capacity) ratio (56.49 ± 23.88 in males and 56.29 ± 28.23 in females) compared with general Thai population. Moreover, the reduction of FVC, FEV1, and peak expiratory flow rate (PEFR) values also showed in both male and female subjects. These results suggest that long-term smoke exposure induces obstructive lung abnormality. Moreover, itchy/watery nose, cough, phlegm, and chest pain also reported in these subjects.Conclusion: Wildfire smog could be induced respiratory pathway inflammation and easily collapsible respiratory airways.
Assessment of efficacy of Oseltamivir-Azithromycin combination therapy in prevention of Influenza-A (H1N1)pdm09 infection complications and rapidity of symptoms relief

Ishaqui AA, Khan AH, Sulaiman SAS, Alsultan MT, Khan I, Naqvi AA

Expert Rev Respir Med, 2020 05;14(5):533-541.
PMID: 32053044 DOI: 10.1080/17476348.2020.1730180

Objectives: This study aimed to assess the efficacy of oseltamivir-Azithromycin combination therapy for prevention of Influenza-A (H1N1)pdm09 infection associated complications and early relief of influenza symptoms.Methods: In a retrospective observational cohort study, Influenza-A (H1N1)pdm09 infection hospitalized patients were identified and divided into two groups based on the initial therapy. Group-AV patients were initiated on Oseltamivir without any antibiotic in treatment regimen while Group-AV+AZ patients were initiated on Oseltamivir and Azithromycin combination therapy for at least 3-5 days. Patients were evaluated for different clinical outcomes.Results: A total of 227 and 102 patients were identified for Group-AV and Group-AV+AZ respectively. Multivariate regression analysis showed that incidences of secondary bacterial infections were significantly less frequent (23.4% vs 10.4%; P-value = 0.019) in Group-AV+AZ patients. Group-AV+AZ patients were associated with shorter length of hospitalization (6.58 vs 5.09 days; P-value = <0.0001) and less frequent incidences of respiratory support (38.3% vs 17.6%; P-value = 0.016). Overall influenza symptom severity score was statistically significant less for Group-AV+AZ patients on Day-5 (10.68 ± 2.09; P-value = 0.001) of hospitalization.Conclusion: Oseltamivir-Azithromycin combination therapy was found to be more efficacious as compared to oseltamivir alone in rapid recovery and prevention of Influenza associated complications especially in high risk patients.
Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care

Rossaki FM, Hurst JR, van Gemert F, Kirenga BJ, Williams S, Khoo EM, et al.

Expert Rev Respir Med, 2021 12;15(12):1563-1577.
PMID: 34595990 DOI: 10.1080/17476348.2021.1985762

INTRODUCTION: Low- and middle-income countries (LMICs) bear a high proportion of the global morbidity and mortality caused by COPD. Increased exposure to risk factors throughout life (e.g. malnutrition, indoor and outdoor air pollution, and smoking) is associated with higher COPD prevalence in LMICs and the lack of treatment availability increases avoidable harm.
AREAS COVERED: This review covers the epidemiology and burden of COPD in LMICs, and challenges and recommendations related to health-care systems, prevention, diagnosis, and treatment. Main challenges are related to under-resourced health-care systems (such as limited availability of spirometry, rehabilitation, and medicines). Lack of policy and practical local guidelines on COPD diagnosis and management further contribute to the low diagnostic and treatment rates. In the absence of, or limited number of respiratory specialists, primary care practitioners (general practitioners, nurses, pharmacists, physiotherapists, and community health workers) play an even more pivotal role in COPD management in LMICs.
EXPERT OPINION: Raising awareness on COPD, educating health-care workers, patients, and communities on cost-effective preventive measures as well as improving availability, affordability and proper use of diagnostic and pharmacological and non-pharmacologic treatment in primary care are the key interventions needed to improve COPD prevention, diagnosis, and care in LMICs.
Fulltext Mortality in COVID-19 patients with acute respiratory distress syndrome and corticosteroids use: a systematic review and meta-analysis

Hasan SS, Capstick T, Ahmed R, Kow CS, Mazhar F, Merchant HA, et al.

Expert Rev Respir Med, 2020 Nov;14(11):1149-1163.
PMID: 32734777 DOI: 10.1080/17476348.2020.1804365

OBJECTIVES: The acute respiratory distress syndrome (ARDS) secondary to viral pneumonitis is one of the main causes of high mortality in patients with COVID-19 (novel coronavirus disease 2019). We systematically reviewed mortality in COVID-19 patients with ARDS and the potential role of systemic corticosteroids in COVID-19 patients.
METHODS: Electronic databases and country-specific healthcare databases were searched to identify relevant studies/reports. The quality assessment of individual studies was conducted using the Newcastle-Ottawa Scale. Country-specific proportion of individuals with COVID-19 who developed ARDS and reported death were combined in a random-effect meta-analysis to give a pooled mortality estimate of ARDS.
RESULTS: The overall pooled mortality estimate among 10,815 ARDS cases in COVID-19 patients was 39% (95% CI: 23-56%). The pooled mortality estimate for China was 69% (95% CI: 67-72%). In Europe, the highest mortality estimate among COVID-19 patients with ARDS was reported in Poland (73%; 95% CI: 58-86%) while Germany had the lowest mortality estimate (13%; 95% CI: 2-29%) among COVID-19 patients with ARDS. The median crude mortality rate of COVID-19 patients with reported corticosteroid use was 28.0% (lower quartile: 13.9%; upper quartile: 53.6%).
CONCLUSIONS: The high mortality in COVID-19 associated ARDS necessitates a prompt and aggressive treatment strategy which includes corticosteroids. Most of the studies included no information on the dosing regimen of corticosteroid therapy, however, low-dose corticosteroid therapy or pulse corticosteroid therapy appears to have a beneficial role in the management of severely ill COVID-19 patients.