What is the role of corticosteroids (steroids) in the treatment of COVID-19?

Corticosteroids in COVID-19 Treatment

Corticosteroids are strongly recommended for hospitalized COVID-19 patients requiring oxygen or ventilatory support, but should not be given to patients with mild disease who don't require oxygen. 1

Treatment Recommendations by Disease Severity

Mild COVID-19 (No Oxygen Requirement)

• Do NOT use corticosteroids (strong recommendation, moderate quality evidence) 1, 2
• Corticosteroids may increase risk of viral replication, delay viral clearance, and potentially worsen outcomes in mild cases 2
• No mortality benefit has been demonstrated in this population 1

Moderate to Severe COVID-19 (Requiring Oxygen)

• Use dexamethasone 6 mg daily for up to 10 days (strong recommendation, moderate quality evidence) 1, 2
• Reduces mortality (RR 0.85,95% CI 0.73-0.99) 1
• Reduces need for mechanical ventilation 1
• Alternative: Methylprednisolone 1-2 mg/kg/day for approximately 3 days 1

Critical COVID-19 (Requiring Mechanical Ventilation)

• Use dexamethasone 6 mg daily for 10 days (strong recommendation, moderate quality evidence) 1, 2
• Greatest mortality benefit seen in this population (29.0% vs. 40.7%, RR 0.65,95% CI 0.51-0.82) 1
• Reduces all-cause mortality and IMV requirements 1

Mechanism and Rationale

Corticosteroids work by:

• Suppressing excessive inflammation in severe COVID-19 1, 3
• Reducing cytokine storm and preventing multi-organ damage 3
• Mitigating risk of acute respiratory distress syndrome (ARDS) 3

Important Precautions

Infection Risk

• Corticosteroids suppress immune function and increase risk of secondary infections 4, 5, 6
• Monitor closely for:
  • Bacterial infections
  • Fungal infections (including mucormycosis)
  • Viral reactivation (especially hepatitis B, varicella, measles) 4, 5, 6

Other Adverse Effects

• Hyperglycemia (monitor blood glucose) 1
• Hypertension and fluid retention 5
• Psychiatric effects 6
• Adrenal suppression with prolonged use 6

Special Populations

Patients with Pre-existing Respiratory Conditions

• Continue baseline inhaled corticosteroids at usual dose for asthma/COPD 2
• Do not increase inhaled corticosteroid dose specifically for COVID-19 treatment 2
• Add systemic dexamethasone if oxygen requirements develop 2

Immunocompromised Patients

• Use with caution as corticosteroids may further suppress immunity 4
• Higher risk of progression from upper to lower respiratory tract infection 2
• Consider prophylaxis for opportunistic infections in prolonged use 4, 5, 6

Implementation Algorithm

1. Assess oxygen requirement:

   • Room air saturation ≥95% → No corticosteroids
   • Requiring supplemental oxygen → Start dexamethasone 6 mg daily
   • Requiring mechanical ventilation → Start dexamethasone 6 mg daily

2. Duration of therapy:

   • Standard course: 10 days or until hospital discharge, whichever comes first
   • Do not taper unless treatment extends beyond 10 days

3. Monitoring during therapy:

   • Daily: Vital signs, oxygen requirements
   • Every 48 hours: Blood glucose, electrolytes
   • Monitor for signs of secondary infection (new fever, purulent secretions)

4. Discontinuation:

   • Complete 10-day course if still requiring oxygen
   • Consider earlier discontinuation if rapid clinical improvement and no longer requiring oxygen

Common Pitfalls to Avoid

1. Using corticosteroids in mild disease: This may worsen outcomes and increase viral shedding 1, 2

2. Delaying corticosteroids in severe disease: Early initiation in appropriate patients (requiring oxygen) is key to effectiveness 1

3. Excessive dosing: Higher doses have not shown additional benefit but may increase adverse effects 1

4. Inadequate infection monitoring: Patients on corticosteroids require vigilant monitoring for secondary infections 4, 5, 6

5. Prolonged use without clear indication: Limit to recommended duration to minimize adverse effects 6