Per the most updated (May 27, 2020) World Health Organization (WHO) guidelines for COVID-19, corticosteroid use in COVID-19 patients may be considered in exacerbation of asthma or chronic obstructive pulmonary disease (COPD), septic shock or ARDS, and based off of risk/benefit analysis for individual patients. In general, the recommends against the routine use of systemic corticosteroids for viral pneumonia. Systematic reviews and meta-analysis of coronavirus diseases (SARS-CoV-2, SARS-CoV and MERS-CoV) found that corticosteroids did not significantly reduce the risk of death, did not reduce hospitalization duration, and/or use of mechanical ventilation, and had several adverse effects. Avascular necrosis, psychosis, diabetes, delayed viral clearance, and secondary infections may hinder the use of corticosteroids. [1]
Per the National Institute of Health guidelines, systemic corticosteroids can affect the pathogenesis of viral infections in various ways. In outbreaks of other novel coronavirus infections (i.e., Middle East respiratory syndrome [MERS] and severe acute respiratory syndrome [SARS]), corticosteroid therapy was associated with delayed virus clearance. In severe pneumonia caused by influenza, corticosteroid therapy may worsen clinical outcomes, including secondary bacterial infection and mortality. Conversely, the potent anti-inflammatory effects of corticosteroids are proposed to have a potential therapeutic role in suppressing cytokine-related lung injury. Data on the use of corticosteroids in COVID-19 are limited. The recommendations for the use of corticosteroids in patients with COVID-19 depend on the severity of illness, indication, and underlying medical conditions and should be considered on a case-by-case basis. [2]
Surviving Sepsis Campaign guidelines on the management of critically ill adults with COVID-19 recommend against the use of systemic corticosteroids in mechanically ventilated adults with COVID-19 and respiratory failure (without ARDS). However, in patients who are mechanically ventilated adults with COVID-19 AND have ARDS, the use of systemic corticosteroids is recommended. This is due to weak evidence suggesting methylprednisolone at 1–2 mg/kg/day for 5–7 days was associated with shorter duration of supplemental oxygen use. [3]
Preliminary results of a randomized, controlled trial (RECOVERY) comparing dexamethasone to “usual care” were reported to have a mortality benefit in patients who were critically ill and on ventilators [Table 1]. This same benefit was not seen in patients who were on oxygen therapy alone. Steroid use in COVID-19 has been controversial due to data from Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) being ambiguous. This new data showed dexamethasone 6 mg (either PO or IV) showed a mortality benefit when started around 8-9 days of symptom onset. [4]
An editorial suggests that dexamethasone may be used short term in severe COVID-19, intubated patients, but could also be dangerous during recovery due to persistence of virus and lack of protective antibodies. Intravenous dexamethasone pulse may be given followed by nebulized triamcinolone to concentrate in the lung only. Both could also be given together with natural flavonoid luteolin because of its antiviral, anti-inflammatory, mast cells inhibition properties. This has the potential to be useful against pro-inflammatory cytokine storms, which is associated with high morbidity and mortality in patients with COVID-19. However, steroid use also inhibits the protective function of T and B cells, potentially leading to increased plasma viral load after the patient survives COVID-19. Patients may also be at a risk of secondary, nosocomial infection with steroid use. [5]
An upcoming randomized, controlled trial studied dexamethasone in combination with intravenous immunoglobulin (IVIG) and interferon-beta in critically ill patients with COVID-19. The results of this study have not been published yet, but the last patients have been enrolled. [6]