Systemic Glucocorticoids Should NOT Be Added in Patients with Influenza A, Asthma, and Smoking History
Do not add systemic glucocorticoids to the treatment regimen for patients with influenza A infection, even when asthma and smoking history are present, as the evidence demonstrates significantly increased mortality and secondary infections with corticosteroid use in influenza. 1
Evidence Against Systemic Corticosteroids in Influenza
The data on glucocorticoid use in influenza infection is unequivocal and concerning:
Meta-analysis of 13 observational studies (n=1,917 patients) found an odds ratio for mortality of 3.06 (95% CI: 1.58-5.92) against corticosteroid use in influenza. 1
Analysis of four low-bias trials confirmed these findings with an OR of 2.82 (95% CI: 1.61-4.92) and demonstrated increased risk of superinfection. 1
Glucocorticoid treatment in influenza pneumonia has been associated with significantly worse outcomes including higher mortality, more secondary bacterial infections, and increased ICU length of stay. 2, 1
Corticosteroids can increase the risk of secondary infection and delay viral clearance in respiratory infections. 1
Management of Asthma During Influenza Infection
For the asthma component in this clinical scenario, the approach differs fundamentally from systemic corticosteroid use:
Continue Inhaled Corticosteroids
Patients already on inhaled corticosteroids should continue them at the lowest effective dose to control underlying asthma and avoid adrenal insufficiency. 2, 1
Abrupt withdrawal of glucocorticoids must be avoided due to risk of hypothalamic-pituitary-adrenal axis suppression, particularly in patients receiving >5 mg/day prednisone equivalent. 2, 1
Inhaled vs. Systemic Therapy Distinction
First-line asthma treatment consists of inhaled bronchodilators plus inhaled corticosteroids, NOT systemic corticosteroids. 3
The American College of Chest Physicians recommends reserving systemic corticosteroids only for severe or refractory asthmatic symptoms that persist despite inhaled therapy. 3
Inhaled corticosteroids do not increase the risk of influenza infection in asthma patients (Peto OR: 1.01,95% CI 0.74-1.37). 4
Critical Clinical Pitfalls to Avoid
Do Not Confuse Asthma Exacerbation Management with Influenza Treatment
While systemic corticosteroids may be appropriate for severe asthma exacerbations in non-infected patients, the presence of influenza A infection fundamentally changes this risk-benefit calculation. 1
The smoking history increases baseline infection risk, making systemic immunosuppression even more hazardous. 2
Bacterial Superinfection Risk
Glucocorticoids are associated with dose-dependent risk of serious bacterial and opportunistic infections. 2
Up to one-half of COVID-19 deaths were attributed to secondary bacterial infection in patients receiving corticosteroids, a pattern likely applicable to influenza. 2
Haemophilus influenzae (common in asthma patients) responds to glucocorticosteroids by enhancing biofilm formation and antibiotic resistance. 5
Specific Treatment Algorithm
Step 1: Continue or initiate inhaled corticosteroids (e.g., beclomethasone 400 mcg twice daily) plus inhaled bronchodilators for asthma control. 3, 6
Step 2: Start antiviral therapy (neuraminidase inhibitor) immediately for influenza A. 7
Step 3: If asthma symptoms worsen, escalate to high-dose inhaled corticosteroids plus long-acting beta-agonists before considering systemic steroids. 3
Step 4: Only if life-threatening asthma exacerbation occurs despite maximal inhaled therapy should brief, low-dose systemic corticosteroids be considered (e.g., hydrocortisone 50 mg IV q6h for 48 hours maximum), recognizing this significantly increases infection-related mortality risk. 1, 6