For people taking oral corticosteroids like prednisone (Rayos, Sterapred) on a routine basis for such conditions as asthma, allergies, and arthritis, risk for COVID-19 (and more serious symptoms) may be higher.
According to the Centers for Disease Control and Prevention, oral and intravenous corticosteroids reduce the activity of the immune system, and people who take them may be at an increased risk for severe illness from the virus that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization, admission to the ICU, intubation or mechanical ventilation, or death.
An editorial by endocrinologists and diabetes specialists published in May 2020 in The Journal of Clinical Endocrinology & Metabolism warns that people taking oral corticosteroids like prednisone on a routine basis may be unable to mount a normal stress response to the new coronavirus and are at a high risk of doing poorly if they get COVID-19.
“Corticosteroids may suppress the immune system, which could increase the risk of becoming infected with COVID-19 and also could increase the risk that you could get sicker from the infection,” says editorial coauthor Ursula Kaiser, MD, chief of the division of endocrinology, diabetes, and hypertension at Brigham and Women’s Hospital in Boston.
Raghavendra Mirmira, MD, an editorial coauthor and professor of medicine in the section of endocrinology, diabetes, and metabolism at the University of Chicago, says that the advisory applies to individuals who take prednisone (Deltasone), hydrocortisone (Hydrocort), and dexamethasone (Decadron). (Note that corticosteroids are a type of steroid drug, and all of the corticosteroids mentioned belong to a class known as glucocorticoids.)
Based on data from the National Health and Nutrition Examination Survey from 1998 to 2006, an estimated 1 percent of people in the United States take these types of oral corticosteroids. Individuals take them for a range of conditions that are inflammatory by nature, including severe asthma, chronic obstructive pulmonary disease, emphysema, chronic allergies, rheumatoid arthritis (RA), vasculitis (an inflammation of the blood vessels), and lupus.
Another group of people taking oral corticosteroids are those with an adrenal insufficiency disease called Addison’s disease, according to the Mayo Clinic. The Journal of Clinical Endocrinology & Metabolism editorial notes that they also face higher risks regarding COVID-19. Addison’s affects only about 1 in 100,000 people. With this disease, the adrenal glands, located above each kidney, are damaged and don't produce enough corticosteroid hormones.
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People Taking Oral Corticosteroids Should Continue to Do So
A corticosteroid works by mimicking cortisol to help the body combat inflammation and stress. The drugs, however, have a dual nature. They can reduce the inflammation that causes things like pain in people with RA and exacerbations in people with severe asthma, but they also lower the immune defenses when taken regularly. This immunosuppression may explain why some people taking oral steroid medications regularly may struggle when they get the virus.
“Chronic steroid therapy can affect the body’s immune system [response] to certain infections, particularly fungus infections and
tuberculosis; and it may actually alter the immune system in regard to fighting off certain viruses and bacteria as well,” says Albert Rizzo, MD, chief medical officer with the American Lung Association.
Dr. Mirmira and his coauthors note that people should continue taking their medications as prescribed to keep underlying conditions under control, but Dr. Rizzo emphasizes that the dose makes a difference. “The higher the dose of oral steroids and the longer one takes them, the risk is higher,” he says. “This means that each patient should discuss trying to get on the lowest dose of oral steroids needed to control the underlying chronic condition to decrease the risks.”
Patients should not lower or taper their doses on their own but should consult with their doctor, according to Rizzo.
Upping the Dose May Help if Symptoms Start
If people taking these medications start to experience COVID-19 symptoms, they may actually need to increase their daily oral corticosteroid dose.
“Those who are taking steroids for long periods of time we assume do not have normal adrenal function,” says Mirmira. “To compensate for a lack of adrenal function, their dose may have to be increased to respond to the inflammation caused by COVID.”
The editorial authors recommend if people with known primary or secondary adrenal insufficiency develop symptoms such as a fever and a dry and continuous cough, they should double their oral corticosteroid dose immediately and continue doing so until the fever has subsided. The authors call this a “sick day” rule that many patients should have already been instructed to be following by their doctor. But each patient’s situation is unique, so only make medication dose changes in response to becoming sick after discussion with your specialist physician (such as an endocrinologist or rheumatologist) or primary care doctor.
Do speak to your medical team if you are on long-term oral corticosteroid therapy to determine a plan for adjusting your dose for this type of situation so that you are prepared if you do get sick.
“Every patient who is on long-term replacement corticosteroid therapy follows ‘sick day’ rules that instruct them to double their dose first if they are sick and then call the doctor,” says Mirmira. “Increasing the dose of your steroids when you don’t have normal adrenal gland function could save your life, and waiting to talk to a doctor sometimes can be delayed, and that could make matters worse.”
He adds that in this case there is no downside to doubling the medication in the short term.
And again, the bottom line is that all patients whose doctors have prescribed these daily oral corticosteroid drugs should continue taking them. “Some people might think these medications increase [their] risk of getting infected or increase the severity so [they] should stop taking them,” says Dr. Kaiser, “but they can get very sick from stopping them, so they should not stop.”
A Lesser Risk Posed by Inhaled and Topical Corticosteroids
Corticosteroids are also prescribed in inhaled forms and topical solutions that are applied to the skin. These medications, while in the same class as oral corticosteroids, pose fewer complications, according to Mirmira, because they are usually in lower doses and they have less systemic effect in the body. “Drugs taken by mouth have a greater effect in your entire body and are usually in a higher concentration than inhaled or topical corticosteroids,” Mirmira says.
Many people with asthma, for example, take inhaled corticosteroids because their condition is not severe enough to warrant taking oral medicines.
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These medications include fluticasone propionate (Advair), mometasone (Asmanex), ciclesonide (Alvesco), fluticasone (Flovent), budesonide (Pulmicort), budesonide and formoterol (Symbicort), and beclomethasone (Qvar).
Michael Blaiss, MD, the executive medical director of the American College of Allergy, Asthma & Immunology, estimates that between about 1 in 4 and 1 in 5 patients with asthma use regular inhaled medication. Dr. Blaiss adds that while these medications may suppress the immune system to a degree, that effect is relatively mild.
“There is really minimal systemic absorption, and we really don’t have any significant data that the typical doses of inhaled corticosteroids have any major effect on the immune system,” he says. “When we inhale the corticosteroids, the effect is in the lungs primarily; it doesn’t go throughout the body having an effect.”
Although comprehensive research is yet to be done, Blaiss mentions that there is speculation that inhaled steroids could provide some protection from COVID-19. “The reason is that some of the inhaled corticosteroids may decrease the receptor sites found on the cells in the lungs where the virus binds,” he says.
Why Might Dexamethasone Help in Severe Cases?
If steroid medications might increase the risk of COVID-19, why then can they help some patients who are very sick with COVID-19?
While it may sound contradictory, Blaiss says that the drugs do have the potential to be either harmful or helpful when it comes to COVID-19. “Depending on the situation, they can suppress the immune system and make you more vulnerable to the virus or be a treatment,” he says.
According to the National Institutes of Health (NIH), a combination therapy of corticosteroids and an antiviral agent may reduce symptoms of severe acute respiratory syndrome (a life-threatening respiratory illness) related to COVID-19. And the NIH strongly recommends the corticosteroid dexamethasone as part of a treatment plan in hospitalized patients who require supplemental oxygen, with the greatest effect observed in patients who require mechanical ventilation.
The NIH based its advice on a study published in July 2020 in The New England Journal of Medicine that found that hospitalized COVID-19 patients on oxygen support (either mechanical ventilation or oxygen alone) who received 6 milligrams of dexamethasone daily for up to 10 days had reduced mortality within 28 days compared with similar patients not taking the steroid.
Blaiss explains that many people with severe COVID-19 experience a cytokine storm, an overreaction of the immune system, which releases an overabundance of cytokines (chemicals that, in excess, can cause hyperinflammation and damage the lungs and other organs), according to a report published in October 2020 in the journal Clinica Chimica Acta; International Journal of Clinical Chemistry.
“Dexamethasone stays in the system longer than most steroids and blunts the immune system,” he says.
Remember: Steroid drugs function by dialing down the immune response and reducing inflammation. It’s not necessarily ideal to have the immune response dialed down if you’re counting on it to protect you from the virus that causes COVID-19 or other infections. But if you’re already sick and COVID-19 has ramped up your immune response in an unhealthy way, a steroid drug that can help lessen that response could potentially be helpful, Blaiss explains.