Is There Any Reason to Use Corticosteroids in Coronavirus Treatment?

UPDATE: the science of SARS-CoV-2 is still emerging.

New information has indicated potential benefit from a corticosteroid known as Dexamethasone. Read here for more detail.

The clinical course and disease progression of COVID-19 is still unknown, and in the absence of a treatment with proven efficacy many different therapies are being deployed in hopes of treating those who fall ill.

As in previous outbreaks of Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), some clinicians have turned to corticosteroids to treat COVID-19.

On January 12, 2020, In early stages of the current outbreak the WHO released clinical management interim guidance which advised against the routine use of corticosteroids.

“Given lack of effectiveness and possible harm, routine corticosteroids should be avoided unless they are indicated for another reason,” WHO authors wrote.

A new commentary in The Lancet emphasizes that there is no evidence that patients with COVID-19 associated lung injury will benefit from the addition of corticosteroids to their therapeutic regimen. In fact, it is more likely that they will be harmed by the addition.

Authors of the commentary point to several studies validating their conclusions, such as a retrospective observational study in which 159 out of 309 patients critically ill with MERS were given corticosteroids.

“Patients who were given corticosteroids were more likely to require mechanical ventilation, vasopressors, and renal replacement therapy…administration of corticosteroids was not associated with a difference in 90-day mortality (adjusted odds ratio 0.8, 95% CI 0.5—1·1; P = 0.12) but was associated with delayed clearance of viral RNA from respiratory tract secretions (adjusted hazard ratio 0.4, 95% CI 0.2–0·7; P = 0·0005).”

The commentary authors also examined corticosteroid treatment in other populations, such as influenza patients. They cite a 2019 systematic review and meta-analysis in which more mortality was observed in patients who were given corticosteroids, alongside an increased length of stay in intensive care and even the rate of secondary bacterial or fungal infections.

“Life-threatening acute respiratory distress syndrome occurs in 2019-nCoV infection,” authors wrote, “however, generalizing evidence from acute respiratory distress syndrome studies to viral lung injury is problematic because these trials typically include a majority of patients with acute respiratory distress syndrome of non-pulmonary or sterile cause.”

The commentary authors point to data across respiratory syncytial virus, SARS, MERS, and influenza which demonstrate potential harm from administration of corticosteroids in a scientifically unproven context. They suggest that there is no reason that COVID-19 would be an exception.

“Corticosteroid treatment should not be used for the treatment of COVID-19 -induced lung injury or shock outside of a clinical trial,” the commentary concludes.

As for what may work instead, there are a variety of treatments in development.

The US Department of Health and Human Services announced that it would expand an existing collaboration with Regeneron Pharmaceuticals to develop several monoclonal antibodies which can be tested for efficacy against 2019-nCoV.

Another promising avenue is remdesivir. The investigational antiviral compound is being evaluated by United States, Chinese, and global health authorities as a possible treatment for COVID-19 . Clinical trials are planned to take place in China.

For the most recent cases in the novel coronavirus outbreak, visit the Contagion® Outbreak Monitor.