Are steroids appropriate for treating viral illnesses?

Steroid Use in Viral Illnesses: A Context-Dependent Decision

Steroids are generally inappropriate for most viral illnesses and can be harmful, but they are strongly indicated for severe COVID-19 requiring oxygen support, where dexamethasone 6 mg daily for 7-10 days reduces mortality by 35% in mechanically ventilated patients. 1, 2

When Steroids Are Beneficial in Viral Infections

Severe COVID-19 (The Primary Exception)

• Dexamethasone 6 mg once daily for up to 10 days is recommended for patients requiring supplemental oxygen or mechanical ventilation, reducing 28-day mortality by 35% in ventilated patients and 20% in those on oxygen alone 1, 2
• The American College of Physicians and World Health Organization support this approach based on high-quality evidence from the RECOVERY trial 2
• The benefit occurs by dampening the hyperinflammatory "cytokine storm" that causes ARDS and organ failure in severe cases 1, 2

Timing Is Critical: The "Forest Fire" Analogy

• Early-stage viral infection (first 4-7 days): Steroids suppress the initial immune response needed to control viral replication, allowing the virus to spread unchecked 1
• Late-stage hyperinflammation (cytokine storm phase): Steroids dampen the overwhelming inflammatory response causing organ damage 3, 1
• Short-course low-dose steroids might suppress the basic 10-15 point increase in inflammatory cytokines in early disease, but cannot suppress the 200-300 point increase once cytokine storm develops, even with high doses 3

When Steroids Are Contraindicated or Harmful

Mild-to-Moderate Viral Illness

• The World Health Organization recommends against systemic corticosteroids for mild or moderate COVID-19 without hypoxemia, as they provide no mortality benefit and may prolong viral shedding 2
• The American Thoracic Society confirms this recommendation with moderate-strength evidence 2

Specific Viral Infections Where Steroids Cause Harm

• Cerebral malaria: Steroids are associated with prolonged coma, higher incidence of pneumonia, and gastrointestinal bleeding 4
• Viral hepatitis: Corticosteroids were harmful in randomized trials 5
• Steroids may mask signs of infection and decrease resistance to localizing infection 4

Risk of Secondary Infections

• Steroids increase susceptibility to bacterial, fungal, and opportunistic infections through immune suppression 6, 4
• In COVID-19 patients, steroid treatment duration correlates with infection rates, particularly after invasive procedures (76.3% growth rate with tracheal aspirate in steroid group vs 54.2% without) 7
• Bacterial infections represent 90% of infectious episodes during steroid therapy, with respiratory infections accounting for 40% 6

Limited Symptomatic Use Only

Viral Rhinosinusitis

• Topical intranasal steroids provide modest symptomatic relief only (73% improvement vs 66% with placebo, NNT=14), but do not treat the infection itself 1
• The American Academy of Otolaryngology suggests these can be used for symptom management, not infection treatment 1

Special Populations Requiring Caution

Patients on Chronic Steroids

• Those already on steroids have altered immune responses and potential adrenal insufficiency 1, 6
• Do not abruptly stop steroids in patients with autoimmune conditions or post-transplant status who develop viral infections—maintain sufficient doses to avoid adrenal crisis while minimizing high-dose exposure 2

Immunocompromised Patients

• Exercise heightened caution in patients with diabetes or underlying immunocompromise, as they have further altered immune responses 2
• Chickenpox and measles can have serious or fatal courses in non-immune individuals on corticosteroids 4

Practical Algorithm for Decision-Making

Step 1: Identify the viral illness and severity

• COVID-19 requiring oxygen/ventilation → Use dexamethasone 6 mg daily 2
• COVID-19 without hypoxemia → Avoid steroids 2
• Other viral illnesses (influenza, rhinovirus, etc.) → Avoid systemic steroids 1, 6

Step 2: Assess timing of infection

• Early phase (<7 days, active viral replication) → Higher risk of harm from steroids 1
• Late phase (cytokine storm, ARDS) → Potential benefit in severe cases only 3

Step 3: Evaluate for contraindications

• Active viral hepatitis or cerebral malaria → Absolute contraindication 4, 5
• Mild symptoms without hypoxemia → No indication 2

Step 4: If steroids are indicated, use appropriate dosing

• Avoid high-dose steroids (>40 mg methylprednisolone equivalent daily), as doses above this threshold increase mortality rather than provide benefit 2
• Use the lowest effective dose for the shortest duration (typically 3-5 days for non-COVID indications) 1

Critical Pitfalls to Avoid

• Never use steroids for mild viral upper respiratory infections—they suppress immune response without clinical benefit 1, 2
• Do not use steroids in early-stage viral illness hoping to prevent progression—this allows unchecked viral replication 3, 1
• Avoid prolonged courses (>14 days) unless specifically indicated, as this dramatically increases infection risk 3, 6
• Screen for latent tuberculosis before initiating steroids, as reactivation may occur 4
• Monitor closely for secondary bacterial and fungal infections, particularly respiratory infections 6, 7