Systemic corticosteroids for management of COVID-19: Saving lives or causing harm?

Abstract

The underlying cause of many complications associated with severe COVID-19 is attributed to the inflammatory cytokine storm that leads to acute respiratory distress syndrome (ARDS), which appears to be the leading cause of death in COVID-19. Systemic corticosteroids have anti-inflammatory activity through repression of pro-inflammatory genes and inhibition of inflammatory cytokines, which makes them a potential medical intervention to diminish the upregulated inflammatory response. Early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the role of corticosteroids was unclear. Corticosteroid use in other indications such as ARDS and septic shock has proven benefit while its use in other respiratory viral pneumonias is associated with reduced viral clearance and increased secondary infections. This review article evaluates the benefits and harms of systemic corticosteroids in patients with COVID-19 to assist clinicians in improving patient outcomes, including patient safety. Dexamethasone up to 10 days is the preferred regimen to reduce mortality risk in COVID-19 patients requiring oxygen support, mechanical ventilation, or extracorporeal membrane oxygenation. If dexamethasone is unavailable, other corticosteroids can be substituted at equivalent doses. Higher doses of corticosteroids may be beneficial in patients who develop ARDS. Corticosteroids should be avoided early in the disease course when patients do not require oxygen support because of potential harms.

Development of a novel score model to predict hyperinflammation in COVID-19 as a forecast of optimal steroid administration timing

“…The timing of administering corticosteroids is one of the key points for improving the pathophysiology of COVID-19. In a previous RECOVERY Trial, the mortality benefit of corticosteroid therapy in COVID-19 was only evident in those with a symptom duration of seven days or more ( 6 , 20 ). However, a higher death rate in the dexamethasone group was observed in patients with a symptom duration of fewer than seven days ( 20 ).…”

“…It has been reported that administering corticosteroids too early in the phase of COVID-19 lowers the inflammatory status and disease severity, increasing the viral load and causing harm to these patients ( 6 ). Thus, a scoring system that can predict hyper-inflammation rates requiring corticosteroid administration is required.…”

Mechanisms and clinical evidence to support melatonin's use in severe COVID-19 patients to lower mortality

“…Dexamethasone is an example of a drug used for this purpose since it lowers the innate immune response of hosts. It has been successfully used in the UK to reduce the mortality of the severely-ill COVID-19 patients [95] , Dexamethasone suffers from serious side effects, since corticosteroids reduce viral clearance, increase secondary infections and perturb metabolism [96] , [97] . Similar to dexamethasone, melatonin downregulates the innate immunity but unlike the corticosteroid, melatonin promotes the adaptive immunity as well as inhibits the entrance and replication of the SARS-CcV-2.…”

Immunity after COVID-19 Recovery and Vaccination: Similarities and Differences

“…After the initial uncertainty during the onset of COVID-19 pandemic, glucocorticosteroids, mainy dexamethasone, are a standard therapy in severe disease course [ 87 ]. However, due to their immunosuppressive potential and potential harms, high doses of corticosteroids should be avoided early in the disease course, when patients do not require oxygen support [ 88 ].…”