Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Technique [Volume 86, Issue 5]

Administrative buildings hit by summer break-ins and burglaries'Army of Darkness' a timeless cult classic, even better as new release on director's cut DVDAvoiding regret: advice from a fifth-year seniorBasketball's Hewitt committed to winBringing mean machines to lifeBroadening academic horizons with minors and certificatesChorale, glee club prepare to entice campus with their vocale spectacles, looking for new membersCollier drafted, traded away to HoustonCo-op club centered on social funDefense, skill positions give football a bright outlook for the seasonDVD provides higher quality, more information vs. VHSExperience India in AtlantaFifth Street Project will give DuPree College of Management a new homeFight SongsFirst car in college can be cheapFootball and Beesball build on their success by expanding their stadiumsFrat Rush events excite campusFreshman aides program involves new students earlyFreshmen are high achieversGet your yum-yums hereGrads get subsidized health careGTCN-it's always onHousing Department changes loft policy to preserve student safetyHow do I get my tickets for football games?Internet cheating conspiracy exposed in CaliforniaI remember the days when the Stinger went up the HillIt's the most beautiful old car in the world...Jackets kick off the season against HokiesKid Rock will rock your face offLack of electives creates well-rounded dilemmaMetallic mayhem reigns supreme at Robot Battles 2000MLR offers more than just musicMolder leads talented new golf team into challenging fall seasonMoney and food: the essentials of survivalMovie version should be spectacularMusician's Network works for more music, music, musicN.C. State chancellor, president help students move into dormsNew Dungeons and Dragons movie hyped at Dragon*ConOlive's dry as a martiniOrchestra growing strongOrganization helps students find their niche on campusOverloads: what to do when every single class you need is fullPackaging Research Center offers opportunityPaint walls black, hang out in nude, options if you live off campusParents of Joe Morse continue search for sonPrepare for traveling adventures with some good booksPretty faces paired with 'Ugly' plotPros and cons of popular places to study on campusReal ramblin' recks stay activeResponsibility goes beyond cashSecret life of a pledgeSecurity on campus: how safe are we?Sewer renovation to affect East Campus students, parkingSGA Plans for Upcoming School YearStudent publications announce fall staff meeting schedulesStudent success through ADAPTS programTake me right to the theater, Jeeves!Tech harriers look to stretch their wings and run rampantTech Toy assembly and instructionsTech welcomes new department chairsThere's no shame in finding a tutorThe Women's Resource Center seeks to make campus yoursThis journey is the beginning of the rest of your lifeTiger-striped home of LSU students upsets neighborsTop textbook site recognizedTrinket is truly 'Set to Explode'Undiscovered talent takes the plunge at AtlantisUse your brain; read some booksU[sic]GA to fight admissions policy rulingVolleyball takes on international flairWelcome from USC Prez J.R. SpriggleWhat makes "The South's Liveliest College Newspaper" tick?When you tire of dining at Brittain, WoodruffWhite and Tillman taken early in draft, Hamilton to be a Tampa Bay Buccanee

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19

International audienc