Systemic Corticosteroids for Asthma Exacerbation with COVID-19
Yes, systemic corticosteroids are recommended for asthma exacerbations in patients with COVID-19, but only if the patient requires supplemental oxygen, noninvasive ventilation, or mechanical ventilation. 1
Critical Decision Algorithm
Step 1: Assess Oxygen Requirements
If patient requires oxygen support (supplemental oxygen, noninvasive ventilation, or mechanical ventilation):
- Strongly recommend dexamethasone 6 mg once daily for up to 10 days 1, 2
- This single dose addresses both the COVID-19 inflammatory response and the asthma exacerbation simultaneously 2
- The European Respiratory Society provides a strong recommendation (moderate-quality evidence) for corticosteroids in COVID-19 patients requiring oxygen 1
If patient does NOT require supplemental oxygen:
- Strongly recommend AGAINST systemic corticosteroids 1
- The European Respiratory Society explicitly states corticosteroids should NOT be offered to hospitalized COVID-19 patients not requiring oxygen (strong recommendation, moderate-quality evidence) 1
- Evidence suggests worse outcomes when systemic corticosteroids are used in COVID-19 patients with asthma who do not require oxygen 3
Evidence-Based Rationale
Mortality Benefit in Oxygen-Requiring Patients
- Dexamethasone 6 mg daily reduces mortality by 35% in patients on mechanical ventilation and 20% in those requiring supplemental oxygen 2
- The American Thoracic Society found that corticosteroids probably decrease mortality in ARDS (RR 0.84,95% CI 0.73-0.96, moderate certainty) 1
- Multiple large trials including RECOVERY demonstrated consistent mortality reduction in oxygen-requiring COVID-19 patients 1, 2
Unique Considerations for Asthma
- Type 2 inflammation in asthma directly inhibits antiviral immunity 4
- Corticosteroids may restore impaired antiviral immunity in asthma patients through suppression of type 2 inflammation, making them potentially beneficial even in viral infections 4
- Asthma itself does not appear to be an independent risk factor for severe COVID-19 5, 6
Specific Implementation Details
Preferred Regimen
- Dexamethasone 6 mg once daily (oral or intravenous) for up to 10 days 1, 2
- This is the only corticosteroid with proven mortality benefit in COVID-19 2
- If dexamethasone is unavailable, methylprednisolone 32 mg daily can be substituted, though evidence is less robust 2
Duration and Monitoring
- Continue for up to 10 days or until hospital discharge, whichever comes first 1, 2
- Monitor daily oxygen saturation and respiratory status 2
- Watch for signs of secondary bacterial infection requiring empiric antibiotics 2
- Provide prophylactic anticoagulation due to high thrombotic risk in critically ill COVID-19 patients 2
Critical Pitfalls to Avoid
Do Not Use Corticosteroids Without Oxygen Requirement
- The RECOVERY trial showed no benefit and potential harm in patients not requiring oxygen 2, 7
- Using systemic corticosteroids in COVID-19 patients with asthma who do not require oxygen is associated with worse outcomes 3
Safety Monitoring
- Corticosteroids probably increase risk of serious hyperglycemia (RR 1.11,95% CI 1.01-1.23) 1
- May increase risk of gastrointestinal bleeding 1
- Monitor for secondary infections 2
Inhaled Corticosteroids Are Different
- Continue maintenance inhaled corticosteroids for asthma control—they are safe and should not be discontinued 5, 6
- Inhaled corticosteroids may even confer some protection against severe COVID-19 by reducing ACE-2 expression 5
- The question specifically addresses systemic corticosteroids for acute exacerbation, not maintenance inhaled therapy 8
Summary Algorithm
- Check oxygen saturation on room air 2, 7
- If SpO2 <94% or requiring any oxygen support: Start dexamethasone 6 mg daily 1, 2
- If SpO2 ≥94% on room air with minimal symptoms: Do NOT use systemic corticosteroids 1, 3
- Continue maintenance inhaled corticosteroids regardless 5, 6
- Monitor for hyperglycemia, secondary infection, and thrombosis 1, 2