What is the review on corticosteroids?

From the Guidelines

Corticosteroids should not be used routinely in COVID-19 patients, as the current evidence does not support their use in reducing mortality, shortening the duration of pneumonia, or shortening hospital stay. The use of corticosteroids in COVID-19 patients is a topic of ongoing debate, with some studies suggesting potential benefits in specific patient populations, such as those with severe respiratory distress syndrome (ARDS) or septic shock. However, the majority of the evidence suggests that corticosteroids do not provide a significant benefit in terms of mortality or morbidity in COVID-19 patients 1.

Some key points to consider when evaluating the use of corticosteroids in COVID-19 patients include:

• A meta-analysis of systemic corticosteroid use in COVID-19 patients found that corticosteroids did not reduce the risk of mortality, shorten the duration of pneumonia, or shorten hospital stay 1.
• A study of critically ill COVID-19 patients found that corticosteroids improved arterial oxygenation and PaO2/FiO2 ratio in the first 3 to 5 days, but did not improve overall survival 1.
• The use of low-dose, short-course corticosteroids (e.g., methylprednisolone 30-80 mg/d for 3-5 days) did not appear to improve patient outcomes in a cohort of 137 COVID-19 patients 1.

In contrast, other studies have suggested potential benefits of corticosteroids in specific patient populations, such as those with septic shock. For example, a Cochrane systematic review found that low-dose hydrocortisone significantly reduced the risk of death at 28 days compared with placebo in patients with septic shock 1. However, these findings are not directly applicable to COVID-19 patients, and the use of corticosteroids in this population should be approached with caution.

In terms of the potential risks and benefits of corticosteroids, it is essential to consider the following:

• Corticosteroids can cause a range of side effects, including hyperglycemia, hypertension, weight gain, mood changes, increased infection risk, osteoporosis, adrenal suppression, and skin thinning.
• The use of corticosteroids can also lead to rebound inflammation and adrenal insufficiency if not tapered properly.

Overall, the decision to use corticosteroids in COVID-19 patients should be made on an individual basis, taking into account the patient's specific clinical circumstances and the potential risks and benefits of treatment. The current evidence does not support the routine use of corticosteroids in COVID-19 patients, and their use should be reserved for specific patient populations where the potential benefits outweigh the risks 1.

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.