Can prednisone be used to treat wheezing in patients with Covid-19 (Coronavirus disease 2019)?

Prednisone for Wheezing in COVID-19 Patients

Prednisone should be used for wheezing in COVID-19 patients who require oxygen supplementation, but should not be used in those with mild COVID-19 who don't require oxygen. 1

Recommendations Based on Oxygen Requirements

Patients Requiring Oxygen

• Corticosteroids (including prednisone) are recommended for COVID-19 patients who require supplemental oxygen, non-invasive ventilation, or invasive mechanical ventilation 1
• The European Respiratory Society strongly recommends corticosteroid treatment for patients with COVID-19 requiring oxygen or ventilatory support 1, 2
• Dexamethasone 6 mg daily for up to 10 days is the most studied regimen, but prednisone at equivalent doses can be used as part of the corticosteroid class effect 1, 2
• Corticosteroids have shown a statistically significant reduction in mortality in patients requiring oxygen (26.2% vs 23.3% in standard care vs dexamethasone) 1

Patients NOT Requiring Oxygen

• Corticosteroids (including prednisone) are strongly recommended AGAINST for patients with COVID-19 who do not require supplemental oxygen 1
• No mortality benefit was evident in patients not requiring supplemental oxygen, and there may be potential harm (14.0% vs 17.8% in standard care vs dexamethasone) 1
• The European Respiratory Society strongly recommends against corticosteroid use in hospitalized COVID-19 patients not requiring oxygen 1, 2

Mechanism and Benefits

• Corticosteroids reduce excessive inflammation and dysregulated immune response that play important roles in severe COVID-19 progression 1, 3
• Corticosteroids have potent anti-inflammatory and immunosuppressive effects, reducing proinflammatory cytokines and chemokines 3
• In the RECOVERY trial, corticosteroids demonstrated a significant mortality benefit in patients requiring oxygen or ventilatory support 1, 4
• A systematic review and meta-analysis suggests a class effect of steroids with an overall odds ratio for mortality of 0.70 (95% CI 0.48-1.01) 1

Dosing Considerations for Wheezing

• For wheezing in COVID-19 patients requiring oxygen, prednisone can be used at equivalent doses to dexamethasone 6 mg daily (approximately 40 mg prednisone) 1, 2
• Short courses (7-10 days) are recommended to minimize adverse effects 2, 3
• Methylprednisolone can be considered at 1-2 mg/kg/day for a short course of about 3 days as an alternative 2, 5

Important Cautions

• Corticosteroids may suppress immune response and potentially increase the risk of bacterial infections if used in non-severe COVID-19 3
• Potential adverse effects include hyperglycemia, secondary infections, hypokalemia, and delayed viral clearance 3, 4
• Corticosteroids should not be used in the treatment of non-severe COVID-19 patients as they may slow recovery and increase the risk of complications 3
• In patients with suspected bacterial co-infection, appropriate antibiotics should be considered alongside corticosteroids 1

Clinical Decision Algorithm

1. Assess oxygen requirement:

   • If patient requires supplemental oxygen → Use prednisone
   • If patient does not require supplemental oxygen → Avoid prednisone 1

2. For patients requiring oxygen with wheezing:

   • Start prednisone 40 mg daily (equivalent to dexamethasone 6 mg)
   • Continue for 7-10 days or until clinical improvement 2
   • Monitor for hyperglycemia and secondary infections 3

3. For patients not requiring oxygen with wheezing:

   • Use supportive care and bronchodilators instead of corticosteroids 1
   • Consider other causes of wheezing and treat accordingly 1

The evidence strongly supports using corticosteroids only in COVID-19 patients requiring oxygen supplementation, with clear mortality benefits in this population, while avoiding their use in milder cases where potential harms may outweigh benefits.