Recommended Steroid Dose for COVID-19 Patients
For COVID-19 patients, dexamethasone 6 mg once daily for up to 10 days is the recommended steroid dose, but it should only be administered to patients requiring supplemental oxygen or ventilatory support. 1, 2
Patient Selection for Steroid Therapy
Recommended for:
- Patients requiring supplemental oxygen
- Patients requiring non-invasive ventilation
- Patients requiring mechanical ventilation
Not Recommended for:
- Patients not requiring supplemental oxygen
- Patients with mild disease who can be managed at home
Evidence-Based Dosing Recommendations
The European Respiratory Society strongly recommends corticosteroids for COVID-19 patients requiring oxygen or ventilatory support based on high-quality evidence 1. The RECOVERY trial, which provides the strongest evidence, used dexamethasone 6 mg daily for 10 days and demonstrated:
- 35% reduction in 28-day mortality for patients on invasive mechanical ventilation (29.0% vs. 40.7%, RR = 0.65) 1, 2
- 20% reduction in 28-day mortality for patients on supplemental oxygen (21.5% vs. 25.0%, RR = 0.80) 1, 2
- No benefit in patients not requiring oxygen (17.0% vs. 13.2%, RR = 1.22) 1, 2
Higher vs. Standard Dose Considerations
Recent evidence cautions against higher doses of dexamethasone:
- The RECOVERY trial found that higher dose corticosteroids (dexamethasone 20 mg daily for 5 days followed by 10 mg daily for 5 days) significantly increased mortality in patients requiring simple oxygen compared to standard dose (19% vs. 12%, rate ratio 1.59) 3
- The COVID STEROID 2 trial showed that 12 mg/day of dexamethasone did not statistically improve outcomes compared to 6 mg/day in patients with severe hypoxemia 4
- The ROIDS-Dose trial found that weight-based dosing (0.2 mg/kg) was not superior to the standard 6 mg dose 5
Alternative Corticosteroids
If dexamethasone is unavailable, alternative corticosteroids may be considered:
- Methylprednisolone (OR 0.48,95% CI 0.16-1.46)
- Hydrocortisone (OR 0.67,95% CI 0.35-1.29) 2
Some studies suggest potential benefit with higher-dose methylprednisolone (40 mg twice daily) compared to standard dexamethasone dosing 6, but this is not supported by major guidelines.
Duration of Treatment
- Standard duration is 10 days based on the RECOVERY trial protocol 1, 2
- Treatment can be discontinued earlier if the patient is discharged from the hospital 2
Monitoring and Adverse Effects
Monitor patients on dexamethasone for:
- Hyperglycemia
- Hypokalemia
- Secondary infections
- Hypertension
- Acne-like skin rash
- Delayed viral clearance 2
Special Considerations
For patients already on corticosteroids for other conditions (e.g., COPD exacerbation):
- If on prednisolone for COPD and diagnosed with COVID-19, continue current prednisolone course
- Only add dexamethasone if COVID-19 causes additional oxygen requirements beyond baseline 2
- Avoid increasing corticosteroid doses in patients with asthma or COPD during COVID-19 infection unless clinically indicated 2
Combination Therapy
Consider adding tocilizumab in patients who are progressing despite corticosteroid treatment, as this combination has been shown to reduce disease progression and mortality 2.