Can steroids help alleviate viral symptoms?

Can Steroids Help Viral Symptoms?

Steroids should generally be avoided in most viral infections, as they do not provide meaningful benefit for mild disease and may cause harm, with the critical exception of severe COVID-19 requiring oxygen support, where dexamethasone 6 mg daily reduces mortality.

Context-Dependent Recommendations

For COVID-19 Specifically

Severe COVID-19 (requiring oxygen or mechanical ventilation):

• Dexamethasone 6 mg once daily (oral or IV) for up to 10 days is strongly recommended 1
• This reduces 28-day mortality by 35% in patients on mechanical ventilation and 20% in those requiring supplemental oxygen 1
• Multiple medical societies including the American College of Physicians recommend this approach based on robust evidence from the RECOVERY trial 1, 2

Mild COVID-19 (not requiring oxygen):

• Steroids are harmful and should be avoided 3
• Patients receiving steroids have 5.97 times higher odds of progressing to severe disease compared to those not receiving steroids 3
• Mortality odds are increased (OR 1.35) 3
• Duration of fever (7.4 vs 6.7 days), viral clearance (18.9 vs 16.5 days), and hospital stay (20.8 vs 15.2 days) are all significantly prolonged with steroid use 3

Timing is critical: Administering steroids before antiviral drugs in COVID-19 pneumonia significantly increases rates of intubation (81.3% vs 33.3%), ICU admission (75.0% vs 29.4%), and ECMO induction (31.3% vs 7.8%) 4. If steroids are needed, antiviral drugs should be initiated first 4.

For Other Viral Infections

Viral rhinosinusitis (common cold/viral sinus infection):

• Topical intranasal steroids may provide modest symptomatic relief but do not treat the infection itself 5
• The benefit is small: 66% improve with placebo at 14-21 days versus 73% with steroid therapy (number needed to treat = 14) 5
• This is purely for symptom management, not disease modification 5

General viral infections:

• Steroids were found to be harmful in viral hepatitis 6
• Historical evidence from SARS-CoV and MERS-CoV showed steroid use was associated with increased morbidity and mortality 5
• Steroids may suppress early viral immune responses, allowing viral replication to progress unchecked 5

The Immunological Rationale

The "forest fire" analogy explains steroid timing 5:

• Early viral infection: Like a small fire from a cigarette butt—steroids may extinguish the initial inflammatory response but allow viral replication to spread
• Cytokine storm phase: Like a raging forest fire—steroids can dampen the overwhelming inflammatory response that causes organ damage 5, 2

The key distinction: Steroids work when the problem is excessive inflammation (cytokine storm), not when the problem is active viral replication 5, 2.

Critical Caveats and Pitfalls

Avoid these common mistakes:

• Do not use systemic steroids for mild viral symptoms—they prolong illness and increase complications 3
• Do not continue prednisone above 20 mg/day in viral infections 5
• Do not use steroid injections during active viral infection, as they increase infection risk and cause prolonged immunosuppression (up to 4 weeks with methylprednisolone) 5
• Do not confuse symptomatic relief (topical nasal steroids for congestion) with disease treatment 5

Special considerations:

• Patients on chronic steroids have altered immune response and potential adrenal insufficiency 5
• Dexamethasone and betamethasone may have shorter durations of immune suppression compared to methylprednisolone 5

Practical Algorithm

1. Identify the viral infection and severity
2. For COVID-19:
   • Mild (no oxygen needed) → Avoid steroids 3
   • Severe (oxygen/ventilation needed) → Dexamethasone 6 mg daily 1
3. For other viral infections:
   • Systemic steroids → Avoid (harmful or no benefit) 6
   • Topical nasal steroids → May use for symptom relief only in viral rhinosinusitis 5
4. If steroids are necessary: Start antiviral therapy first when available 4