COVID-19 and corticosteroids

By Professor Bob Hancox, Otago Medical School and Waikato Hospital

9 April 2020

There are several issues around corticosteroids and COVID-19 that clinicians may encounter or patients will ask about. The first of these is whether patients should continue with inhaled corticosteroids. The answer for patients with asthma is discussed by Professor Beasley and is a straightforward “Yes” – with the advice to use the smallest effective dose or prescribe anti-inflammatory reliever therapy with a combined budesonide/formoterol inhaler taken as required for symptom control, with or without maintenance budesonide/formoterol.

For patients with COPD, the advice is less straightforward. Many patients with COPD do not benefit from inhaled corticosteroid treatment and their use is associated with an increased risk of pneumonia. Whether this includes COVID-19 pneumonia is unknown, but the risk of pneumonia appears to be dose-related and when inhaled corticosteroids are indicated, we should aim to use low doses. International guidelines recommend inhaled corticosteroids for COPD patients with features of asthma (i.e. Asthma-COPD Overlap). Among other COPD patients, those with recurrent exacerbations or high blood eosinophils are most likely to benefit.

What about oral corticosteroids? Short courses of oral corticosteroids have an important role in the management of exacerbations of both asthma and COPD and at the moment there are no data to suggest that these should be avoided. Both international asthma (GINA) and COPD (GOLD) guidelines recommend treating exacerbations normally during the COVID-19 pandemic.

For patients on long-term oral corticosteroids for respiratory or other conditions, there are few data, but it is likely that they are at an increased risk from COVID-19. This may be due to the immunosuppressive effects of corticosteroids and also due to the underlying co-morbidity. While we should strive to use the lowest effective dose, abrupt discontinuation of oral corticosteroids is unlikely to be an option. Patients on long-term corticosteroid treatment may have underlying adrenal insufficiency and need a boost in their dose if they become unwell with COVID. 

A more controversial issue is whether patients with COVID-19 should be treated with corticosteroids. Much of the lung pathology from COVID-19 is thought to be due to the immune response and many patients in overseas cohorts have been treated with high doses of steroids. To date there is no evidence that this has been beneficial. Corticosteroid treatment in SARS and MERS coronavirus disease has not been shown to improve prognosis, but has been associated with harms and delayed viral clearance. On this basis, the WHO currently recommends that routine use of corticosteroids should be avoided in COVID-19. 

The risks and benefits of oral corticosteroids may be different in critically ill patients. The Surviving Sepsis Campaign recommends using corticosteroids in patients with refractory shock or in mechanically ventilated patients with acute respiratory distress syndrome. However, these are weak recommendations based on low quality evidence derived from other critically ill patients without COVID-19. A discussion of this evidence is beyond the scope of this article.

As the COVID-19 pandemic evolves, new evidence is being published every day. Most of this evidence is anecdotal or observational, but controlled trials are underway everywhere we will eventually have better evidence to guide us. For the time being, there is no evidence that we should change our current use of inhaled or oral corticosteroids. 

References

  1. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Read Online: Critical Care Medicine | Society of Critical Care Medicine. 2020;Online First.
  2. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020;395(10223):473-5.
  3. World Health Organization. Clinical management of severe acute respiratory infection (‎SARI)‎ when COVID-19 disease is suspected: interim guidance, 13 March 2020. Geneva: World Health Organization; 2020 2020.  Contract No.: WHO/2019-nCoV/clinical/2020.4.
  4. Global Initiative for Asthma. 2020 [7/4/2020]. Available from: https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/
  5. Global Initiative for COPD. 2020 [7/4/2020]. Available from: https://goldcopd.org/gold-covid-19-guidance/