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Corticosteroids for Treatment of COVID-19

Corticosteroids have the potential for the treatment of COVID-19, but their administration is still controversial due to limited clinical evidence. The CDC and WHO recommend avoiding using corticosteroids for COVID-19, but the Surviving Sepsis Campaign recommends their use in COVID-19 patients who have acute respiratory distress syndrome (ARDS).

Corticosteroids for Treatment of COVID-19



The epidemic of COVID-19 caused by a new variant of the 2019 coronavirus or SARS-CoV-2 is an extreme situation and challenge for clinicians around the world. Management of this disease is unclear due to the lack of clinical evidence regarding the effectiveness of medical treatment for COVID-19. One of the medicaments considered to have the potential to treat COVID-19 is corticosteroids.

Using corticosteroids to treat COVID-19, SARS, and MERS

The effectiveness of corticosteroids in COVID-19 treatment is based on the use of corticosteroids for handling SARS and MERS.

Despite genetic differences, SARS-CoV, MERS-CoV, and SARS-CoV-2 each cause inflammation and damage to the pulmonary alveoli, causing acute lung damage (acute lung injury and acute respiratory distress syndrome). In theory, corticosteroids are useful for suppressing the inflammatory process, so their use for the treatment of COVID-19 to suppress lung damage due to SARS and MERS.

Besides being intended for anti-inflammatory effects in cases of acute pulmonary parenchymal damage, corticosteroids are generally given to SARS and MERS patients who experience septic shock. A report published recently reported that approximately 5% (140 people) of COVID-19 patients experienced a septic shock.

Ironically, despite its widespread use, the efficacy of corticosteroids in septic shock is still unclear. In patients with severe hypoxemic respiratory failure due to Coronavirus infection, The shock that occurs often caused by the consequences of increased intrathoracic pressure (during invasive ventilation) that limits / reduces cardiac filling and not because of vasoplegia. Therefore, the benefits of steroid therapy with indications of septic shock are still questionable.

Clinical data available regarding the use of corticosteroids for COVID-19

In a retrospective observational study of 309 critical adult patients due to MERS-CoV, approximately 50% of patients were given corticosteroids. In that group, it turns out there are more patients who need mechanical ventilators, vasopressor agents, or kidney transplant therapy than those without corticosteroids. However, after adjusting for confounding factors, corticosteroid administration had no impact on patient mortality but was associated with delayed clearance of viral RNA from the airway secretions.

In a meta-analysis of corticosteroid use in SARS patients, there were only four studies with conclusive data, but all indicated adverse effects rather than benefits. Adverse effects found in this meta-analysis are:

  1. The emergence of psychosis in the administration of high doses of corticosteroids
  2. Viremia levels of the second and third week after SARS infection are higher than controls in corticosteroid administration with an average duration of about 5 days
  3. Risk of diabetes and avascular necrosis
  4. The publication of research data has not supported the use of corticosteroids in COVID-19. Currently, open-label research is still ongoing that evaluates the impact of 1 mg/kg weight/day intravenous methylprednisolone in COVID-19 patients in China.


Recommendations Regarding the Use of Corticosteroids for COVID-19

Both the guidelines from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) of the United States recommend avoiding the use of corticosteroids for handling COVID-19 due to lack of clinical data. The exception is if there are other indications of corticosteroid administration, for example, if the patient has a septic shock.

However, the latest guidelines from the Surviving Sepsis Campaign recommend the use of systemic corticosteroids in COVID-19 patients with Acute Respiratory Distress Syndrome (ARDS), although this is still considered a weak recommendation due to low-quality clinical evidence.

Use of Oral / Inhaled Corticosteroids for Other Indications Amidst the COVID-19 Pandemic

Although recommendations from the CDC and WHO suggest avoiding corticosteroids for COVID-19, inhaled and systemic corticosteroids are still given for other indications.

WHO allows the administration of antenatal corticosteroids to women who are at risk of preterm delivery (gestational age 24 to 34 weeks) if there is no clinical evidence of maternal infection.

The use of oral corticosteroids or inhalation is still recommended in patients with asthma and chronic obstructive pulmonary disease (COPD) according to the latest Global Initiative For Asthma (GINA) and Global Initiative For Chronic Obstructive Lung Disease (GOLD) guidelines.

Although there are no official guidelines, some endocrinologists recommend the administration of hydrocortisone corticosteroids 50-100 mg, three times a day, in patients with adrenal insufficiency while adhering to COVID-19 prevention guidelines.

For patients with Rheumatic Musculoskeletal Diseases, European League Against Rheumatism (EULAR) has not recommended stopping corticosteroids or other drugs that include disease-modifying anti-rheumatic drugs (DMARD) in patients with COVID-19.

Conclusion
The unavailability of adequate clinical data regarding the benefits of corticosteroid administration for the management of COVID-19 makes WHO and the CDC recommend to avoid using this drug for COVID-19. This recommendation can still change along with the results of studies on the use of corticosteroids for handling COVID-19, which is still ongoing in China.

On the other hand, the latest guidelines from the Surviving Sepsis Campaign recommend the use of corticosteroids for COVID-19 patients who have acute respiratory distress syndrome (ARDS).

Although the use of corticosteroids for COVID-19 is controversial, the use of corticosteroids for other indications, both oral and inhalation, is still permissible. This is supported by recommendations from WHO, GINA, GOLD, and EULAR.

Writer: Dr Eduward, Internist

References
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