Is it safe to give corticosteroids to a COVID-19 patient?

Is It Safe to Give Steroids to a COVID-19 Patient?

Yes, corticosteroids are safe and beneficial for hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation, but they should NOT be given to patients who do not require oxygen support, as they may increase mortality in this group. 1, 2

Key Recommendations by Disease Severity

For Patients Requiring Oxygen Support or Mechanical Ventilation

• Corticosteroids probably reduce all-cause mortality slightly (risk reduction of approximately 30 fewer deaths per 1000 patients) in hospitalized COVID-19 patients requiring respiratory support 2
• Dexamethasone is the preferred agent at low doses (typically 6 mg daily) for up to 10 days 3, 4
• When administered within the first 7 days of admission, corticosteroids reduce mortality (OR 0.73) and decrease ICU transfers (OR 0.72) 5

For Patients NOT Requiring Oxygen Support

• Corticosteroids should be avoided as they may increase mortality in this population (RR 1.24, indicating 24% increased risk of death) 6
• The routine use of corticosteroids in patients without hypoxemia is not recommended 7

For Refractory Shock

• Low-dose corticosteroid therapy is suggested for adults with COVID-19 and refractory shock (typical regimen: hydrocortisone 200 mg per day) 1

Optimal Corticosteroid Regimen

Type and Dose

• Dexamethasone is the most studied and recommended corticosteroid 2, 3, 4
• Low-dose regimens are superior to high-dose regimens - survival benefit was observed specifically with low dosage corticosteroids (RR 0.90) 6
• If dexamethasone is unavailable, methylprednisolone, prednisolone, or hydrocortisone can be substituted at equivalent doses 3
• Higher doses may be considered only in patients who develop ARDS 3

Timing

• Administer within the first 7 days of admission for maximum benefit 5
• Early administration in the disease course (before oxygen requirement) should be avoided 3

Patient Subgroups Most Likely to Benefit

The mortality benefit is particularly impressive in:

• Younger patients (<65 years of age) 5
• Female patients 5
• Patients with elevated inflammatory markers:
  • C-reactive protein ≥150 mg/L 5
  • Interleukin-6 ≥20 pg/mL 5
  • D-dimer ≥2.0 µg/L 5

Safety Profile and Important Caveats

Infection Risk

• No increased risk of bacteremia or fungemia was observed in corticosteroid-treated versus non-corticosteroid-treated COVID-19 patients 5
• However, be vigilant for Strongyloides and amebic infections in at-risk patients, as these can progress to catastrophic complications even with short corticosteroid courses 8
• Screen patients from endemic areas for parasitic infections before initiating corticosteroids 8

Historical Concerns Not Supported in COVID-19

• Earlier concerns about delayed viral clearance from SARS and MERS studies have not been definitively demonstrated to worsen outcomes in COVID-19 when used appropriately 7
• The systematic review found no difference in rates of adverse events (RR 1.13) or secondary infections (RR 0.87) 6

Ventilation Outcomes

• Corticosteroids may increase ventilator-free days (mean difference 2.6 days more) 2
• The evidence for new need for invasive mechanical ventilation remains uncertain due to methodological limitations 2

Common Pitfalls to Avoid

1. Do not use corticosteroids in non-hypoxemic patients - this is associated with increased mortality 6
2. Do not use high-dose/short-duration regimens for septic shock 9
3. Do not delay administration beyond 7 days of admission in appropriate candidates 5
4. Do not substitute high doses thinking more is better - low-dose dexamethasone is the evidence-based approach 6, 3

Strength of Evidence

The recommendation is based on moderate-certainty evidence from multiple randomized controlled trials including 7,930 participants, with the landmark RECOVERY trial providing the strongest data 2. The Surviving Sepsis Campaign guidelines provide strong recommendations for oxygen saturation targets and weak recommendations for corticosteroid use in refractory shock 1.