When are corticoids (corticosteroids) indicated for respiratory viral infections?

From the Guidelines

Corticosteroids are indicated for severe respiratory viral infections, such as COVID-19, requiring oxygen support or mechanical ventilation, where dexamethasone 6mg daily for up to 10 days has shown benefit by reducing inflammation and mortality. This recommendation is based on the most recent and highest quality study, the RE-COVERY trial, a multicenter RCT conducted in 176 NHS hospitals, which found that dexamethasone reduced 28-day mortality by 35% amongst patients on invasive mechanical ventilation and by 20% amongst patients on supplemental oxygen therapy with or without noninvasive ventilation 1.

Key Points to Consider

• The use of corticosteroids in respiratory viral infections should be carefully considered, as they may suppress the immune system and potentially worsen outcomes in routine cases of viral respiratory infections like the common cold, influenza, or uncomplicated COVID-19.
• However, in specific situations such as severe COVID-19, viral-induced asthma or COPD exacerbations, and croup, corticosteroids may be beneficial in reducing airway inflammation and improving outcomes.
• The anti-inflammatory effects of corticosteroids can help reduce harmful inflammatory responses that can cause tissue damage and respiratory compromise, but their use must be balanced against the potential risks of delaying viral clearance and increasing the risk of secondary infections.
• The American College of Rheumatology guidance for the management of rheumatic disease in adult patients during the COVID-19 pandemic also endorses the use of low-dose glucocorticoids when clinically indicated, and acknowledges that higher doses may be necessary in the context of severe, vital organ-threatening disease 1.

Specific Recommendations

• For severe COVID-19 requiring oxygen support or mechanical ventilation, dexamethasone 6mg daily for up to 10 days is recommended.
• For viral-induced asthma or COPD exacerbations, prednisone 40-60mg daily for 5-7 days may be indicated to reduce airway inflammation.
• For croup, a single dose of dexamethasone 0.6mg/kg (maximum 10mg) can reduce symptoms. The guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients also suggest that corticosteroids may be beneficial in reducing mortality and improving outcomes in patients with severe pneumonia 1.

From the Research

Indications for Corticoids in Respiratory Viral Infections

• Corticoids, also known as corticosteroids, are indicated for use in certain respiratory viral infections, including COVID-19, particularly in patients with severe disease or acute respiratory distress syndrome (ARDS) 2, 3, 4.
• The use of corticosteroids in patients with COVID-19 and ARDS may reduce mortality, according to a systematic review and meta-analysis 2.
• However, in patients with severe COVID-19 but without ARDS, the evidence regarding the benefit of corticosteroids is inconsistent and of very low quality 2.

Benefits and Risks of Corticosteroid Therapy

• Corticosteroids have anti-inflammatory properties, which can be beneficial in reducing inflammation and improving outcomes in patients with severe respiratory viral infections 3, 4.
• However, corticosteroid therapy can also predispose patients to secondary bacterial and invasive fungal infections, such as mucormycosis, particularly in patients with underlying immunosuppressive conditions or uncontrolled diabetes mellitus 5.
• The use of corticosteroids can also suppress the hypothalamic-pituitary-adrenal (HPA) axis, leading to adrenal insufficiency, and can have other serious side effects 4.

Guidelines for Corticosteroid Use

• Guidelines suggest the use of methylprednisolone at a dose of 20-40 mg/day or equivalent for up to 10 days in patients with COVID-19 pneumonia and respiratory failure, as well as in exacerbations of asthma and COPD 4.
• Corticosteroid treatment should be minimized in terms of dosage and duration, and tapering should be gradual to avoid adrenal insufficiency 4.
• The use of corticosteroids in other respiratory viral infections, such as influenza, is not recommended due to the potential for increased mortality and nosocomial infection 3.