What is the review on corticosteroids?

From the Guidelines

Corticosteroids should not be used routinely in COVID-19 patients, as the evidence generally favors against their use in critically ill patients, with the decision to administer corticosteroids made on an individual basis following discussion with the intensivist. The use of corticosteroids in COVID-19 patients has been studied in several trials, with a meta-analysis of systemic corticosteroid use in COVID-19 patients finding that corticosteroids did not reduce the risk of mortality, shorten the duration of pneumonia, or shorten hospital stay 1. However, the duration of fever was significantly lower in COVID-19 patients who received corticosteroids than patients who did not receive corticosteroids.

Some key points to consider when evaluating the use of corticosteroids include:

• The potential benefits of corticosteroids, such as reducing inflammation and improving symptoms, must be weighed against the potential risks, such as increased infection risk and adrenal suppression.
• The evidence from studies of corticosteroid use in other severe respiratory virus infections, such as SARS and MERS, suggests that corticosteroids may not provide a clear benefit and may even cause harm 1.
• The decision to use corticosteroids should be made on a case-by-case basis, taking into account the individual patient's condition and the potential risks and benefits of treatment.
• Other studies have suggested that low-dose corticosteroids may be beneficial in certain situations, such as in patients with septic shock, but the evidence is not yet conclusive 1.

In terms of specific dosing and administration, the evidence suggests that:

• Low-dose corticosteroids, such as hydrocortisone, may be more effective and have a lower risk of side effects than high-dose corticosteroids.
• The duration of treatment with corticosteroids should be as short as possible, to minimize the risk of side effects and dependence.
• Corticosteroids can be administered through multiple routes, including oral, intravenous, inhaled, topical, and injectable forms, depending on the condition being treated and the individual patient's needs.

Overall, the use of corticosteroids in COVID-19 patients should be approached with caution, and the decision to use them should be made on a case-by-case basis, taking into account the latest evidence and the individual patient's condition.

From the FDA Drug Label

WARNINGS General Rare instances of anaphylactoid reactions have occurred in patients receiving corticosteroid therapy Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy subjected to any unusual stress before, during and after the stressful situation Cardio-Renal Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment. Immunosuppression and Increased Risk of Infection Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens

The review on corticosteroids indicates that they can cause several adverse effects, including:

• Anaphylactoid reactions
• Cardio-renal effects such as elevation of blood pressure, salt and water retention, and increased excretion of potassium
• HPA axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment
• Immunosuppression and increased risk of infection with any pathogen It is essential to use corticosteroids with caution and carefully monitor patients for potential adverse effects, especially when used in high doses or for prolonged periods 2.

From the Research

Overview of Corticosteroids

• Corticosteroids have been used in modern medicine for decades, with various indications and treatment settings showing both benefits and harm 3.
• The benefits of corticosteroids include improved disease-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality 3.
• However, the harm of corticosteroids is well-documented, with adverse effects including hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness 3.

Use of Corticosteroids in Asthma

• Inhaled corticosteroids (ICSs) and long-acting inhaled beta(2)-agonists (LABAs) are recommended treatment options for asthma 4.
• A systematic review compared the clinical effectiveness and tolerability of ICSs (fluticasone propionate and budesonide) and LABAs (formoterol fumarate and salmeterol xinafoate) administered alone or in combination 4.
• The review found that fluticasone and formoterol appeared to provide improved therapeutic benefits versus budesonide and salmeterol, respectively 4.
• Another study found that oral/systemic corticosteroids were commonly used for asthma management, and long-term or repeated short-term use was associated with an increased risk of acute and chronic adverse events 5.

Combination Therapy with Corticosteroids

• A study compared the effect of combination products (salmeterol and fluticasone propionate) with increased doses of inhaled corticosteroids (ICSs) on several outcome variables in patients with asthma 6.
• The study found that combination products had a significant improvement in pulmonary function, but no statistically significant differences in other endpoints such as asthma exacerbation 6.
• Another study found that combination products provided a statistically significant improvement in lung function and symptoms, but no significantly increased protection against exacerbation 6.

Corticosteroid Replacement Therapy in Critical Illness

• Corticosteroid replacement therapy may improve morbidity and mortality in specific target groups of critically ill patients, particularly those with severe systemic inflammation 7.
• However, the appropriate diagnosis of adrenal insufficiency and steroid resistance in target cells remains a challenge, and indication and practical use of corticosteroid replacement therapy are generally directed by clinical symptoms and features 7.
• Recent studies have demonstrated improvements in morbidity with corticosteroid replacement therapy, but additional studies are required to refine the target groups and optimal use of this therapy 7.