Hostname: page-component-7c8c6479df-24hb2 Total loading time: 0 Render date: 2024-03-29T10:14:29.376Z Has data issue: false hasContentIssue false

Corticosteroid use for 2019-nCoV infection: A double-edged sword

Published online by Cambridge University Press:  23 April 2020

Sundus Nasim
Affiliation:
MBBS, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
Sohail Kumar*
Affiliation:
MBBS, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
Dua Azim
Affiliation:
MBBS, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
Zehra Ashraf
Affiliation:
Faculty of Pharmacy, Jinnah University for Women, Karachi, Pakistan
Qiraat Azeem
Affiliation:
MBBS, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
*
Author for correspondence: Sohail Kumar, E-mail: sohailjaipal@yahoo.com
Rights & Permissions [Opens in a new window]

Abstract

Type
Letter to the Editor
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

To the Editor—A newly emergent coronavirus disease 2019 (COVID-19), first recognized in the city of Wuhan, China, in early December 2019, is a respiratory tract infection. On March 11, 2020, with >118,000 cases reported in 114 countries and nearly 4,291 deaths worldwide, this virus was labeled a pandemic by the World Health Organization (WHO).1 Responding to the uncertain clinical progression of COVID-19 and the absence of any particular therapy with established efficacy, the medical and scientific communities are working to develop various therapies to achieve an effective cure for the COVID-19. Some physicians have suggested corticosteroids to treat COVID-19 as in previous outbreaks of severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS).

Although corticosteroid use has been reported in hospitalized patients with severe disease, contradictory evidence from the WHO regarding corticosteroid use in some viral illnesses suggests that this evidence is not definitive. In severe cases of COVID-19, complications (eg, pneumonia, acute respiratory distress syndrome, cardiomyopathy, arrhythmia, acute kidney failure, sepsis, and septic shock) can occur along with complications associated with prolonged hospitalization (eg, secondary bacterial infections). In severely ill patients with these complications, corticosteroids have been used widely.Reference Zhao, Zhang and Xu2-Reference Yang, Yu and Xu4 During a retrospective review in Wuhan Union Hospital,Reference Wang, Jiang and He5 the efficacy of the early use of short-term corticosteroids was investigated and compared with a control group using the clinical record and chest computed tomography (CT) scans. Among these groups, one group was intravenously administered methylprednisolone at a dose of 1–2 mg/kg/d for 5–7 days. The results included the rapid return of body temperature to a normal and improvement in peripheral capillary oxygen saturation (SpO2). Chest CTs showed improved absorption focus with methylprednisolone administration. Parallel to these reported observations, another Chinese study showed similar outcomes with early use of high-dose corticosteroids along with quinolone in patients with severe acute respiratory syndrome coronavirus (SARS-CoV).Reference Zhao, Zhang and Xu6

Contrary to the aforementioned results, the current interim guidance from WHO on clinical management of severe acute respiratory infection when COVID-19 is suspected (released January 28, 2020),7 advises against the utilization of corticosteroids during this disease unless it is indicated for a comorbid clinical condition. The wide use of this drug in the management of SARS-CoV and the Middle East respiratory syndrome coronavirus (MERS-CoV) worsened the immune response and caused diffuse alveolar damage, even though it did suppress lung inflammation to some extent.Reference Tang, Chan and Wong8,Reference Arabi, Balkhy and Hayden9 In a review of observational studies on SARS patients with progressively worsening pulmonary conditions or abnormalities on chest X-ray, those administered corticosteroids showed no benefit but did show possible side effects such as steroid-induced psychosis and avascular necrosis. This review classified the treatment regimens as early treatments and rescue treatments administered in later stages of the disease progression.Reference Stockman, Bellamy and Garner10 Russell et alReference Russell, Millar and Baillie11 summarized the results of various case-control studies of SARS patients; they showed a higher incidence of psychosis with high-doses of corticosteroid administration, as well as diabetes, delayed viral clearance, and avascular necrosis. They also reported a delay in viral RNA clearance from the respiratory tract following corticosteroid administration in a MERS-CoV infection.Reference Russell, Millar and Baillie11

Considering these findings, no evidence exists to indicate that the use of corticosteroids will benefit patients infected with 2019-nCoV, and it could worsen their condition. In conclusion, we understand that the ongoing coronavirus pandemic is a challenging and unprecedented time for the world. Although few studies do suggest a potential role for the use of corticosteroids in COVID-19 treatment, the current literature does not provide any definitive evidence for or against their use. Thus the use of corticosteroid could be regarded as a double-edged sword. Corticosteroid treatment ought not to be utilized for the treatment of COVID-19 outside of a clinical trial, and caution should be exercised until further evidence regarding corticosteroid use specific to COVID-19 emerges. However, we recommend that clinicians proceed with extreme caution when administering corticosteroids, making it certain that the benefits outweigh the risks.

Acknowledgments

None.

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References

WHO director-general’s opening remarks at the media briefing on COVID-19. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Published March 11, 2020. Accessed April 7, 2020.Google Scholar
Zhao, Z, Zhang, F, Xu, M, et al.Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China J Med Microbiol 2003;52:715720.CrossRefGoogle Scholar
Wang, D, Hu, B, Hu, C, et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020;323:10611069.CrossRefGoogle ScholarPubMed
Yang, X, Yu, Y, Xu, J, et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020. doi: 10.1016/S2213-2600(20)30079-5.CrossRefGoogle ScholarPubMed
Wang, Y, Jiang, W, He, Q, et al.Early, low-dose and short-term application of corticosteroid treatment in patients with severe COVID-19 pneumonia: single-center experience from Wuhan, China. medRxiv 2020. doi: 10.1101/2020.03.06.20032342.Google Scholar
Zhao, Z, Zhang, F, and Xu, M, et al.Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. J Med Microbiol 2003;52:715720.CrossRefGoogle Scholar
Clinical management of severe acute respiratory infection when COVID-19 is suspected. Interim guidance by World Health Organization. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Published March 13, 2020. Accessed April 7, 2020.Google Scholar
Tang, NL, Chan, PK, Wong, CK, et al.Early enhanced expression of interferon-inducible protein-10 (CXCL-10) and other chemokines predicts adverse outcome in severe acute respiratory syndrome. Clin Chem 2005;51:23332340.CrossRefGoogle ScholarPubMed
Arabi, YM, Balkhy, HH, Hayden, FG, et al.Middle East respiratory syndrome. N Engl J Med 2017;376:584594.10.1056/NEJMsr1408795CrossRefGoogle ScholarPubMed
Stockman, LJ, Bellamy, R, Garner, P.SARS: systematic review of treatment effects. PLoS Med 2006;3:15251531.CrossRefGoogle ScholarPubMed
Russell, CD, Millar, JE, Baillie, JK.Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020;395:473475.CrossRefGoogle Scholar