Inhaled Corticosteroids for COVID-19 Treatment
There is no recommended dose of inhaled corticosteroids (ICS) for COVID-19 treatment as they are not indicated for this purpose based on current guidelines. 1, 2
Current Evidence and Recommendations
Primary Recommendations
- Systemic corticosteroids (not inhaled) are recommended for COVID-19 patients requiring oxygen or ventilatory support 1
- The standard regimen is dexamethasone 6 mg daily for 10 days (oral or intravenous) for hospitalized patients requiring oxygen 1
- ICS are not recommended for COVID-19 treatment in any severity category 2
Evidence for Inhaled Corticosteroids
A Cochrane systematic review found that in mild COVID-19, inhaled corticosteroids:
- May reduce time to symptom resolution by approximately 4 days
- Probably reduce hospital admission or death
- Do not significantly affect all-cause mortality
- Have uncertain effects on serious adverse events 3
The PRINCIPLE trial specifically evaluated inhaled budesonide (800 μg twice daily for 14 days) in high-risk outpatients with COVID-19 and found:
- Improved time to recovery by approximately 3 days
- Potential but not statistically significant reduction in hospitalizations 4
Disease Severity Considerations
- For mild COVID-19 (no oxygen requirement): Corticosteroids are not recommended 1, 2
- For moderate to severe COVID-19 (oxygen requirement): Systemic corticosteroids are recommended, not inhaled 1
- For critical COVID-19: Systemic corticosteroids are recommended, not inhaled 1
Potential Risks of Inhaled Corticosteroids in COVID-19
- May increase risk of secondary infections 2
- May delay viral clearance 2
- Associated with higher mortality and hospitalization rates compared to standard non-steroid COVID-19 therapy in some studies 5
Special Populations
- Patients with pre-existing asthma or COPD should continue their usual ICS regimen but should not increase doses due to COVID-19 2
- No evidence supports increasing ICS doses in patients with underlying respiratory conditions during COVID-19 infection 2
Comparative Effectiveness
- When compared to systemic corticosteroids, a study found that IV methylprednisolone (1 mg/kg) resulted in better outcomes than both IV dexamethasone (6 mg daily) and inhaled budesonide (1 mg twice daily) in terms of hospital stay and ventilation requirements 6
Algorithm for Corticosteroid Use in COVID-19
Assess COVID-19 severity:
- Mild (no oxygen requirement): No corticosteroids
- Moderate-severe (oxygen requirement): Systemic dexamethasone 6 mg daily for 10 days
- Critical: Systemic dexamethasone 6 mg daily for 10 days
For patients with pre-existing respiratory conditions:
- Continue baseline ICS at usual dose
- Do not increase ICS dose for COVID-19 treatment
- Add systemic dexamethasone if oxygen requirements develop
In conclusion, while some evidence suggests potential benefits of inhaled corticosteroids in mild COVID-19, major guidelines do not recommend their use specifically for COVID-19 treatment. The standard of care for COVID-19 patients requiring respiratory support remains systemic corticosteroids, particularly dexamethasone 6 mg daily for up to 10 days.