Simvastatin in Critically Ill Patients with Covid-19.
REMAP-CAP Investigators None., Hills TE., Lorenzi E., Berry LR., Shyamsundar M., Al-Beidh F., Annane D., Arabi Y., Aryal D., Au C., Beane A., Bhimani Z., Bonten M., Bradbury CA., Brunkhorst FM., Burrell A., Buxton M., Calfee CS., Cecconi M., Cheng AC., Cove ME., Detry MA., Estcourt LJ., Fitzgerald M., Goligher EC., Goossens H., Green C., Haniffa R., Harrison DA., Hashmi M., Higgins AM., Huang DT., Ichihara N., Jayakumar D., Kruger PS., Lamontagne F., Lampro L., Lawler PR., Marshall JC., Mason AJ., McGlothlin A., McGuinness S., McQuilten ZK., McVerry BJ., Mouncey PR., Murthy S., Neal MD., Nichol AD., O'Kane CM., Parke RL., Parker JC., Rabindrarajan E., Reyes LF., Rowan KM., Saito H., Santos M., Saunders CT., Seymour CW., Shankar-Hari M., Sinha P., Thompson BT., Turgeon AF., Turner AM., van de Veerdonk FV., Weis S., Young IS., Zarychanski R., Lewis RJ., McArthur CJ., Angus DC., Berry SM., Derde LPG., Webb SA., Gordon AC., McAuley DF.
BACKGROUND: The efficacy of simvastatin in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear. METHODS: In an ongoing international, multifactorial, adaptive platform, randomized, controlled trial, we evaluated simvastatin (80 mg daily) as compared with no statin (control) in critically ill patients with Covid-19 who were not receiving statins at baseline. The primary outcome was respiratory and cardiovascular organ support-free days, assessed on an ordinal scale combining in-hospital death (assigned a value of -1) and days free of organ support through day 21 in survivors; the analyis used a Bayesian hierarchical ordinal model. The adaptive design included prespecified statistical stopping criteria for superiority (>99% posterior probability that the odds ratio was >1) and futility (>95% posterior probability that the odds ratio was <1.2). RESULTS: Enrollment began on October 28, 2020. On January 8, 2023, enrollment was closed on the basis of a low anticipated likelihood that prespecified stopping criteria would be met as Covid-19 cases decreased. The final analysis included 2684 critically ill patients. The median number of organ support-free days was 11 (interquartile range, -1 to 17) in the simvastatin group and 7 (interquartile range, -1 to 16) in the control group; the posterior median adjusted odds ratio was 1.15 (95% credible interval, 0.98 to 1.34) for simvastatin as compared with control, yielding a 95.9% posterior probability of superiority. At 90 days, the hazard ratio for survival was 1.12 (95% credible interval, 0.95 to 1.32), yielding a 91.9% posterior probability of superiority of simvastatin. The results of secondary analyses were consistent with those of the primary analysis. Serious adverse events, such as elevated levels of liver enzymes and creatine kinase, were reported more frequently with simvastatin than with control. CONCLUSIONS: Although recruitment was stopped because cases had decreased, among critically ill patients with Covid-19, simvastatin did not meet the prespecified criteria for superiority to control. (REMAP-CAP ClinicalTrials.gov number, NCT02735707.).