What is the role of oral corticosteroids (such as prednisone) in treating viral respiratory infections in patients with and without underlying respiratory conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Oral Corticosteroids in Viral Respiratory Infections

Oral corticosteroids should NOT be routinely used for viral respiratory infections in patients without underlying respiratory disease, as they do not provide benefit and may increase mortality and secondary infections. 1, 2

Patients WITHOUT Underlying Respiratory Disease

Acute Viral Bronchitis

• Do not prescribe oral corticosteroids for acute bronchitis in healthy adults - the evidence is clear and consistent showing no benefit, and the clinical course resolves spontaneously after approximately 10 days without steroid intervention 2

Influenza

• Avoid corticosteroids in patients with influenza - observational studies demonstrate an odds ratio of dying of 3.06 (95% CI, 1.58-5.92) against corticosteroids, with increased risk of superinfection 1
• Analysis of four low-risk-of-bias trials showed consistent findings (OR, 2.82; 95% CI, 1.61-4.92) 1

COVID-19 and Viral Pneumonia

• Corticosteroids are contraindicated for routine use in viral pneumonia unless the patient has severe disease with high inflammatory markers (CRP >150 mg/L) or septic shock refractory to vasopressors 1, 3
• Multiple international guidelines (WHO, CDC, European, Asian) consistently recommend against routine corticosteroid use in COVID-19 except for specific severe presentations 1
• Studies on influenza have found corticosteroids exacerbate infection and increase mortality rates 1

Community-Acquired Pneumonia (Severe Cases Only)

• Consider corticosteroids ONLY in hospitalized patients with severe CAP and high inflammatory markers (CRP >150 mg/L) or septic shock 1, 3
• Use 5-7 days at daily dose <400 mg IV hydrocortisone equivalent 1
• Benefits include: mortality reduction (RR 0.67; 95% CI 0.45-1.01), reduced mechanical ventilation need (RR 0.45; 95% CI 0.26-0.79), and ARDS prevention (RR 0.24; 95% CI 0.10-0.56) 1
• Risk of hyperglycemia increases (RR 1.49; 95% CI 1.01-2.19) 1

Patients WITH Underlying Respiratory Disease (Asthma/COPD)

Asthma Exacerbations

• Continue maintenance inhaled corticosteroids during viral respiratory infections - do not discontinue these medications as unsolicited changes may lead to severe exacerbations 4
• Oral corticosteroids are appropriate for acute asthma exacerbations triggered by viral infections, following standard asthma exacerbation protocols 4

COPD Exacerbations

• Prescribe prednisone 30-40 mg daily for 5 days for acute COPD exacerbations (which may be triggered by viral infections) 5, 2
• This improves lung function, oxygenation, shortens recovery time, and reduces hospitalization duration 5, 2
• Do NOT extend treatment beyond 5-7 days - longer courses increase adverse effects without additional benefit 5
• Do NOT use corticosteroids to prevent exacerbations beyond the first 30 days following the initial event 5

Chronic Stable Disease

• Continue maintenance inhaled corticosteroids in patients with asthma or COPD during viral respiratory infections 4, 6
• Do not use long-term oral corticosteroids for stable disease 2
• Inhaled corticosteroids combined with long-acting bronchodilators are appropriate for patients with FEV1 <50% predicted or frequent exacerbations 2

Critical Pitfalls to Avoid

• Never prescribe oral corticosteroids for simple viral upper respiratory infections or acute bronchitis in healthy adults - this provides no benefit and increases harm 2
• Do not confuse viral bronchitis with COPD exacerbation - only the latter benefits from corticosteroids 2
• Avoid corticosteroids in influenza pneumonia - they increase mortality 1, 3, 7
• Do not discontinue inhaled corticosteroids in asthma/COPD patients during viral infections - this can precipitate dangerous exacerbations 4
• Monitor for hyperglycemia, secondary infections, and other adverse effects when corticosteroids are indicated 1, 8
• Corticosteroids suppress immune function and increase infection risk with all pathogens (viral, bacterial, fungal) 8

Special Monitoring Considerations

When corticosteroids are indicated:

• Screen for latent tuberculosis before prolonged therapy 8
• Avoid exposure to varicella and measles in non-immune patients 8
• Screen for hepatitis B before immunosuppressive treatment 8
• Rule out latent amebiasis and Strongyloides infestation 8
• Monitor blood glucose closely 1, 3