COVID-19 Outpatients and Systemic Corticosteroid Use

There were a lot of lessons learned from the first year of the SARS-CoV-2/COVID-19 pandemic, from transmission, to isolation/quarantine, to treatment modalities. We are still learning about what works best for those with COVID-19 who require treatment, but early on it felt like we were building the plane as we flew it.

Considering the world has experienced 535 million COVID-19 cases and 6.3 million deaths, it will likely take us time to truly understand the dynamics of this disease and pandemic. One treatment that we increasingly have been evaluating is the use of corticosteroids, especially for those experiencing severe illness requiring hospitalization. However, what about in outpatient settings?

A new study published in JAMA recently discussed the use of systemic corticosteroids in the US for those requiring outpatient care during the COVID-19 pandemic. From April 2020 to August of 2021, data from the US Food and Drug Administration (FDA’s) Sentinel System was utilized.

Patients with COVID in the prior 183 days and with the use of systemic corticosteroids within the prior 90 days were excluded. Of those 576,885 eligible patients in Medicare and 766,105 in Sentinel, the mean ages were 74.6 years and 48.5 years, respectively. Of those groups, 16.4% in the Medicare cohort and 9.4% in the Sentinel group received systemic corticosteroids as an outpatient within 14 days of their COVID-19 diagnosis.

The research team noted that “The proportion of patients initiating corticosteroids in the South was higher than in any other region. Use increased with age until approximately 79 years. Corticosteroid use increased over time from 2.2% initiating in April 2020 to 21.1% in August 2021 in Medicare, and from 2.2% in April 2020 to 13.8% in July 2021 in Sentinel.”

Among pharmacy dispensing, the most commonly used corticosteroids were dexamethasone in Medicare (43.8%) and prednisone in Sentinel (34.1%). The most common prescriber specialties in Medicare were internal medicine or family/general practice (39.9%) and emergency medicine (18.6%). Treatment often started on the day of COVID-19 diagnosis (58.8% for Medicare vs 51.3% for Sentinel), largely through pharmacy dispensing (70.8%-80.3%) rather than during medical encounters.

On the day corticosteroid use was initiated, 24.7% in Medicare had visited the emergency department vs 22.9% in Sentinel. Interestingly, Azithromycin was utilized frequently as a partner-drug and concomitant therapy.

The authors noted that in mid-2020, a trial conducted within the United Kingdom suggested potential harm for dexamethasone use for those hospitalized patients not requiring oxygen, which was then followed by an October 2020 guideline against systemic corticosteroid use in patients with mild to moderate COVID-19.

This new study suggests that those non-hospitalized patients were frequently given systemic corticosteroids, frequently on the day of diagnosis. As this use increases during the pandemic, additional consideration for safety and efficacy is a necessary point of research. Moreover, this insight is important for future emerging infectious disease threats and preparedness regarding pharmaceutical intervention.