What is the role of corticosteroid (steroid) therapy in the treatment of viral pneumonia?

From the Guidelines

Steroid therapy is recommended for hospitalized COVID-19 patients requiring oxygen, as it has been shown to reduce mortality in this population. The use of corticosteroids in viral pneumonias is a topic of ongoing debate, with evidence suggesting that they may be beneficial in certain circumstances, such as COVID-19 pneumonia with moderate to severe disease requiring oxygen therapy 1. For most viral pneumonia cases, including those caused by influenza or rhinovirus, steroids should be avoided as they may worsen outcomes by suppressing the immune system and potentially allowing viral replication to increase 1.

Key Considerations

• The decision to use steroids should be individualized based on the specific virus, disease severity, and patient factors such as comorbidities.
• Patients receiving steroids should be monitored for potential side effects including hyperglycemia, secondary infections, and psychiatric effects.
• The benefit of corticosteroids in COVID-19 pneumonia comes from dampening the excessive inflammatory response that damages lung tissue in severe viral pneumonia cases, rather than from any direct antiviral effect 1.
• For mild viral pneumonia cases not requiring oxygen, steroids are not recommended and may be harmful.

Evidence-Based Recommendations

• For hospitalized COVID-19 patients requiring oxygen, dexamethasone 6 mg once daily for up to 10 days has become standard treatment, as it reduces mortality in this population 1.
• The use of corticosteroids in patients with severe CAP is conditional, with moderate quality of evidence suggesting that they may be beneficial in certain circumstances 1.
• The Surviving Sepsis Campaign recommendations on the use of corticosteroids in patients with septic shock refractory to adequate fluid resuscitation and vasopressor support should be endorsed 1.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection

The use of steroid therapy, such as prednisone, to treat viral pneumonias is not recommended due to the increased risk of infection and exacerbation of existing infections. Corticosteroids, including prednisone, can suppress the immune system, making it more difficult for the body to fight off viral infections. Therefore, caution should be exercised when considering steroid therapy in patients with viral pneumonias 2.

From the Research

Use of Steroids Therapy to Treat Viral Pneumonias

• The use of corticosteroids in viral pneumonia is a controversial topic, with some studies suggesting benefits and others indicating potential harm 3, 4, 5, 6, 7.
• A study published in 2020 found that dexamethasone decreased mortality in coronavirus disease-2019 (COVID-19) cases, but the evidence from retrospective and observational studies is inconclusive about the use of corticosteroids in COVID-19 3.
• Another study published in 2021 compared the safety and efficiency of dexamethasone and methylprednisolone in the treatment of COVID-19 infection, and found that both steroids are efficient in the management of mild, moderate, and severe COVID-19 pneumonia, with a clear superiority of dexamethasone especially in severe forms 4.
• However, a retrospective study published in 2021 found that administering steroids prior to antiviral drugs soon after symptom onset can aggravate disease severity, and suggested that it may be safer to initiate antiviral drugs first 6.
• A review published in 2012 evaluated the potential benefits and adverse effects of adjunctive therapy with systemic steroids in patients with pneumonia, and found that there are no data to support the well-tolerated use of systemic steroids as a standard of care in pneumonia, neither in mild-to-moderate and severe, nor in bacterial and viral infection 7.
• The use of corticosteroids in pneumonia is still a topic of debate, and more studies are needed to validate the benefit of corticosteroids in COVID-19 and other viral pneumonias 3, 5.
• Some studies suggest that low-dose corticosteroid therapy may be beneficial in severe community-acquired pneumonia, but the evidence is weak and larger trials are needed to provide robust evidence 5.