Should a patient with a history of Intensive Exacerbation of Chronic Obstructive Pulmonary Disease (IECOPD) treated with prednisolone be initiated on dexamethasone after an incidental diagnosis of COVID-19?

Management of Dexamethasone in Patients with IECOPD and Incidental COVID-19

Patients who were already treated for IECOPD with prednisolone and are incidentally diagnosed with COVID-19 do not require additional dexamethasone therapy unless they develop COVID-19-related oxygen requirements.

Assessment of Respiratory Support Requirements

The decision to initiate dexamethasone in a patient with incidental COVID-19 who has already received prednisolone for IECOPD should be based on:

• Oxygen requirements specifically related to COVID-19:

  • If the patient requires supplemental oxygen due to COVID-19 progression (beyond their baseline COPD needs), dexamethasone may be indicated 1, 2
  • If the patient does not require additional oxygen beyond their baseline, dexamethasone should be avoided 1, 2, 3

• Inflammatory markers:

  • Elevated inflammatory markers specifically attributable to COVID-19 (CRP, D-dimer, LDH) may support the need for corticosteroid therapy 1, 4

Evidence-Based Rationale

The European Respiratory Society strongly recommends:

• Offering corticosteroids to COVID-19 patients requiring oxygen, non-invasive ventilation, or mechanical ventilation 1
• NOT offering corticosteroids to COVID-19 patients who don't require supplementary oxygen 1

This recommendation is based on the RECOVERY trial, which demonstrated:

• No mortality benefit in patients not requiring oxygen (17.8% vs 14.0% in dexamethasone vs standard care) 3
• Potential harm in non-hypoxemic patients (rate ratio 1.19,95% CI 0.92-1.55) 2, 3

Clinical Decision Algorithm

1. If patient has already completed prednisolone course for IECOPD:

   • Monitor oxygen requirements
   • If new/increased oxygen needs develop due to COVID-19, initiate dexamethasone 6 mg daily for up to 10 days
   • If no new oxygen requirements, avoid additional steroids

2. If patient is still on prednisolone for IECOPD:

   • Continue current prednisolone course for COPD management
   • Do not add dexamethasone unless COVID-19 causes additional oxygen requirements
   • If COVID-19 progresses to require additional oxygen, consider switching to dexamethasone 6 mg daily

Important Considerations and Pitfalls

• Avoid steroid duplication: Simultaneous administration of prednisolone and dexamethasone without clear indication increases risk of adverse effects without additional benefit 2

• Monitor for steroid-related complications: Hyperglycemia, hypokalemia, secondary infections, and hypertension are common with prolonged or high-dose steroid use 2

• Duration of therapy: Standard dexamethasone course for COVID-19 is 10 days, but this may be adjusted based on clinical response 2, 5

• Alternative corticosteroids: If dexamethasone is unavailable, methylprednisolone or hydrocortisone can be considered as alternatives, as they appear to have similar efficacy 2, 4, 6

By following this evidence-based approach, you can optimize corticosteroid therapy while minimizing unnecessary medication exposure in patients with both IECOPD and incidental COVID-19.