Can oral steroids be used to treat influenza in patients, including pediatric and geriatric individuals, as well as those with compromised immune systems or underlying respiratory conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Oral Steroids Should NOT Be Used to Treat Influenza

Corticosteroids should not be administered for the treatment of influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons such as refractory septic shock, asthma/COPD exacerbation, or pre-existing adrenal insufficiency. 1, 2

Evidence Against Corticosteroid Use in Influenza

The evidence consistently demonstrates harm from corticosteroid use in influenza across multiple populations:

• Meta-analysis of 13 observational studies (n=1,917 patients) showed a mortality odds ratio of 3.06 (95% CI: 1.58-5.92) against corticosteroid use 2
• Analysis of four low-bias trials confirmed these findings (OR: 2.82; 95% CI: 1.61-4.92) with increased risk of superinfection 2
• Corticosteroids are associated with significantly higher mortality, more secondary bacterial infections, and longer ICU stays in influenza pneumonia 2, 3
• Nosocomial infection risk increases substantially (OR 3.16,95% CI 2.09-4.78) 3
• Duration of mechanical ventilation increases by 3.82 days and ICU stay by 4.78 days with corticosteroid treatment 3

Critical Exceptions: When Steroids MUST Be Continued

Patients Already on Chronic Corticosteroids

Do NOT abruptly discontinue steroids in patients already taking them chronically, as this can cause life-threatening adrenal crisis. 2

• Continue glucocorticoids in patients with rheumatic diseases who develop influenza, but reduce to the lowest possible dose to control the underlying disease 2
• Avoid abrupt cessation in patients receiving >5 mg/day prednisone equivalent due to adrenal suppression risk 2
• Patients on chronic steroids (≥20 mg/day prednisolone for >1 month, or ≥1 mg/kg/day in children <20 kg) are considered high-risk for influenza complications 1

Other Valid Indications for Steroids During Influenza

Corticosteroids may be indicated for:

• Septic shock refractory to vasopressors and fluid resuscitation 4
• Asthma or COPD exacerbations complicating influenza 1
• Life-threatening manifestations of underlying rheumatic disease 2

Proper Management Algorithm for Influenza

Primary Treatment: Antiviral Therapy

Initiate neuraminidase inhibitors (oseltamivir 75 mg twice daily for 5 days) immediately in: 1, 5

• All hospitalized patients with suspected influenza
• Patients with severe or progressive illness
• High-risk patients (age <2 years or ≥65 years, pregnant/postpartum women, immunocompromised, chronic cardiopulmonary disease)
• Do not delay treatment while awaiting laboratory confirmation 1, 6

Secondary Bacterial Infection Management

Investigate and empirically treat bacterial coinfection if: 1, 5

• Severe initial presentation
• Clinical deterioration after initial improvement
• Failure to improve after 3-5 days of antiviral treatment

Add antibiotics with good gram-positive coverage (clarithromycin or cefuroxime) intravenously for severe pneumonia 1

Special Populations

Pediatric Patients

• Oral oseltamivir is the antiviral of choice for all ages, with weight-based dosing for children ≥12 months 6
• Children on chronic steroids for asthma requiring continuous/repeated inhaled or systemic steroids are high-risk 1
• Continue necessary steroids for underlying conditions but avoid adding steroids for influenza treatment 2

Patients with Asthma/COPD

• Continue inhaled corticosteroids for asthma/COPD management during influenza 7
• May require systemic steroids specifically for asthma/COPD exacerbation, not for influenza itself 1
• Zanamivir is contraindicated due to bronchospasm risk; use oseltamivir instead 1

Immunocompromised Patients

• Patients on immunosuppressive doses of steroids (≥20 mg/day prednisolone for >1 month) are high-risk 1
• Prioritize immediate antiviral therapy; do not add corticosteroids for influenza treatment 1, 2

Common Pitfalls to Avoid

• Never add corticosteroids thinking they will reduce inflammation in influenza pneumonia—they increase mortality and delay viral clearance 2, 8
• Never abruptly stop chronic steroids in patients who develop influenza—taper gradually while treating influenza with antivirals 2
• Do not withhold antiviral treatment beyond 48 hours in severely ill patients 1, 5
• Do not rely on negative rapid antigen tests to rule out influenza in high-risk patients 6