In a COVID‑19 patient, when are corticosteroids indicated, what is the recommended dexamethasone dose and duration, and how should patients not requiring supplemental oxygen or those already on chronic steroids be managed?

Corticosteroid Use in COVID-19

Corticosteroids should be given to COVID-19 patients requiring supplemental oxygen, noninvasive ventilation, or mechanical ventilation, using dexamethasone 6 mg once daily for up to 10 days, but must NOT be given to patients not requiring oxygen support. 1

Indications for Corticosteroids

Use corticosteroids in these specific situations:

• Patients requiring supplemental oxygen (any form including nasal cannula, high-flow oxygen, noninvasive ventilation, or mechanical ventilation) 1
• The mortality benefit is substantial: 35% reduction in patients on mechanical ventilation and 20% reduction in those on supplemental oxygen 1, 2
• This represents a strong recommendation with moderate quality evidence from multiple international guidelines 1

Do NOT use corticosteroids in:

• Hospitalized patients not requiring supplemental oxygen - this is a strong recommendation against use, as there is no mortality benefit and potential harm 1
• Non-hospitalized patients with COVID-19 1
• Real-world data shows 76% increased risk of 90-day mortality when dexamethasone was given to hospitalized patients on no oxygen 3

Recommended Dexamethasone Dose and Duration

Standard regimen:

• Dexamethasone 6 mg once daily (oral or intravenous) for up to 10 days or until hospital discharge, whichever comes first 1, 2
• This is the only corticosteroid dose and regimen proven to reduce mortality in the landmark RECOVERY trial 1, 2

Alternative corticosteroids if dexamethasone unavailable:

• Methylprednisolone 32 mg once daily can be substituted, though evidence is less robust 4
• Meta-analyses suggest a class effect with hydrocortisone and methylprednisolone showing similar mortality benefits (OR 0.70,95% CI 0.48-1.01) 1

Critical warning about higher doses:

• Do NOT use higher doses - the RECOVERY trial found that dexamethasone 20 mg daily for 5 days followed by 10 mg daily for 5 days significantly increased mortality (rate ratio 1.59,95% CI 1.20-2.10) in patients on simple oxygen 5
• Higher doses also increased pneumonia (10% vs 6%) and hyperglycemia requiring insulin (22% vs 14%) 5

Management of Patients Already on Chronic Steroids

For patients on chronic corticosteroids who develop COVID-19:

• Continue their baseline chronic steroid dose for their underlying condition 1
• If they require supplemental oxygen, add or increase to dexamethasone 6 mg daily (or equivalent) to ensure adequate immunomodulation for COVID-19 1
• The chronic steroid dose alone may be insufficient to address the hyperinflammatory phase of COVID-19 requiring oxygen 1
• If they do not require oxygen, continue only their baseline chronic steroid regimen without escalation 1

Combination Therapy Considerations

Corticosteroids plus tocilizumab:

• Consider adding IL-6 receptor antagonist (tocilizumab) to corticosteroids in patients requiring oxygen or ventilatory support, as this combination reduces disease progression and mortality 1, 6
• Patients most likely to benefit are those in the first 24 hours after receiving ventilatory support or those progressing despite corticosteroid treatment 6

Corticosteroids plus JAK inhibitors:

• The combination of glucocorticoids and baricitinib or tofacitinib could be considered in patients requiring oxygen therapy, noninvasive ventilation, or high-flow oxygen 1

Common Pitfalls to Avoid

Critical errors that increase mortality:

• Starting corticosteroids in patients not requiring oxygen - this shows no benefit and potential harm with increased mortality (rate ratio 1.19,95% CI 0.92-1.55) 2
• Using higher than recommended doses - doses above dexamethasone 6 mg daily increase mortality 5
• Starting corticosteroids too early in the disease course before oxygen requirements develop 3
• Confusing low-flow nasal cannula patients - even patients on simple nasal cannula oxygen benefit from dexamethasone 6 mg daily 2

Safety monitoring requirements:

• Monitor for secondary bacterial infections, particularly pneumonia 5
• Check blood glucose regularly and adjust insulin as needed 5
• Provide prophylactic anticoagulation to all hospitalized COVID-19 patients due to high thrombotic risk 1, 4
• Consider gastrointestinal prophylaxis with proton pump inhibitors 7

Algorithm for Decision-Making

Step 1: Assess oxygen requirement

• No oxygen needed → Do NOT give corticosteroids 1
• Any supplemental oxygen (nasal cannula, high-flow, noninvasive ventilation, mechanical ventilation) → Give dexamethasone 6 mg daily 1, 2

Step 2: Choose corticosteroid

• First choice: Dexamethasone 6 mg once daily 1
• If unavailable: Methylprednisolone 32 mg once daily 4

Step 3: Determine duration

• Continue for up to 10 days or until hospital discharge, whichever comes first 1

Step 4: Consider combination therapy

• If progressing despite corticosteroids or within 24 hours of starting ventilatory support, add tocilizumab 1, 6