What is the role of steroids in treating mild Covid-19 (Coronavirus disease 2019)?

Steroids for Mild COVID-19

Steroids are not recommended for patients with mild COVID-19 as they may increase the risk of disease progression and mortality compared to standard care alone.

Evidence Assessment

The available guidelines provide clear direction regarding corticosteroid use in mild COVID-19:

• A 2020 guideline from Clinical and Molecular Hepatology indicates that potential benefits of corticosteroids in preventing progression of symptoms in mild COVID-19 patients have not been well established 1.

• The 2020 Autoimmunity Reviews publication presents a contrasting view, suggesting that short-course low-dose steroids in early disease stages might suppress the inflammatory response 1. However, this recommendation is based on theoretical benefits rather than robust clinical evidence.

• The most recent evidence from Praxis Medical Insights strongly recommends against offering corticosteroids to patients who do not require supplemental oxygen (strong recommendation, moderate-quality evidence) 2.

Research Evidence

The research evidence strongly supports avoiding steroids in mild COVID-19:

• A 2021 systematic review and meta-analysis found that steroids in non-oxygen requiring COVID-19 patients were associated with:

  • 5.97 times higher odds of progression to severe disease
  • 1.35 times higher odds of death
  • Longer duration of fever (7.4 vs 6.7 days)
  • Delayed viral clearance (18.9 vs 16.5 days)
  • Longer hospital stays (20.8 vs 15.2 days) 3

• A 2021 Cochrane review found moderate-certainty evidence that systemic corticosteroids probably slightly reduce all-cause mortality in hospitalized patients with symptomatic COVID-19, but specifically noted "there is no evidence for asymptomatic or mild disease (non-hospitalised participants)" 4.

Clinical Algorithm for COVID-19 Steroid Use

1. Assess disease severity:

   • Mild disease: No oxygen requirement, no signs of pneumonia
   • Moderate to severe: Oxygen requirement, signs of pneumonia
   • Critical: Respiratory failure, shock, multi-organ dysfunction

2. Treatment recommendations based on severity:

   • Mild COVID-19:

     • Do NOT administer steroids
     • Focus on supportive care
     • Monitor for disease progression

   • Moderate to severe COVID-19:

     • Consider steroids (dexamethasone 6mg daily for up to 10 days) if oxygen requirement present

   • Critical COVID-19:

     • Administer steroids (dexamethasone 6mg daily for up to 10 days)

Potential Harms of Steroids in Mild COVID-19

• Increased risk of progression to severe disease 3
• Higher mortality 3
• Delayed viral clearance 3, 5
• Prolonged hospitalization 3
• Increased risk of secondary infections 2

Key Considerations

• The distinction between mild and moderate-to-severe disease is critical in determining steroid appropriateness
• Oxygen requirement is the primary threshold for considering steroid therapy
• For patients with mild COVID-19 who have other indications for steroids (e.g., COPD exacerbation, asthma), continue usual steroid regimen but do not increase dosage specifically for COVID-19 2

Common Pitfalls to Avoid

• Prescribing steroids for all COVID-19 patients regardless of severity
• Assuming that early steroid use will prevent cytokine storm without evidence
• Overlooking the potential harms of steroids in mild disease
• Failing to distinguish between theoretical benefits and evidence-based recommendations

In conclusion, while steroids have become a mainstay of treatment for severe and critical COVID-19, the evidence clearly shows they should be avoided in mild cases due to potential harms and lack of benefit.