American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 3
(Part 5)
We continue with our discussion this week with the use of glucocorticoids.
The data linked to the impact of glucocorticoids in the therapy in patients infected with Coronavirus disease (Covid) can be considered as a mixed bag.
Understanding the possible risks links with the immunosuppressive effects of glucocorticoids, recent pieces of information suggest that their antiinflammatory abilities may, in theory, help lessen the impact of Covid especially during the late stages of the disease which may indicate episodes of hyperinflammation and/or cytokine storm.
Data suggest that among the younger patients who have undergone solid organ transplantation and those who are getting cancer chemotherapy situated in epidemic hotzones of Italy, majority were receiving glucocorticoids, and have not developed severe Covid complications.
In small cohort studies, therapy being used in Covid–related acute respiratory distress syndrome with methylprednisolone was linked with improved survival and shorter stay in the intensive care unit (ICU).
In another study of patients suffering from Covid and staying in hospitals, dexamethasone use was linked with a lower mortality rate especially in a subgroup of patients getting respiratory support.
These limited information provide an insight that glucocorticoid may provide benefit to patients suffering Covid. These pieces of information are balanced by indirect data from other viral diseases indicating that there is no meaningful advantage, or even that there could be potential harm.
There is no clinical information available, showing benefit from glucocorticoids in the provision of treatment of airway infections related to respiratory diseases caused for example by syncytial virus, influenza, SARS–CoV-1, the virus that causes Covid, or Middle East respiratory syndrome (MERS).
Furthermore, in another study of patients suffering from SARS–CoV-1 or the original Severe Acute Respiratory Syndrome (SARS) pneumonia, the use of glucocorticoids was linked with bad results.
Likewise, glucocorticoid use in influenza pneumonia are linked with significantly bad results including possible higher chance of mortality, more instances of secondary bacterial infections, and increased length stay at the ICU.
In addition to being linked with reemergence of herpes zoster, glucocorticoid treatment is associated with a dose-dependent risk of serious bacterial and opportunistic infections.
This concern serious bacterial and opportunistic infections may be salient, as it was seen in at least one Chinese case series that up to one-half of all Covid–related deaths were associated with secondary bacterial infection.
Based on the available evidence, the American College of Rheumatology task force pushes for the continued standard-of-care glucocorticoid use, at the same time avoiding the abrupt treatment stoppage.
The expert panel is pushing for the utilization of low-dose glucocorticoids when needed and knowing that higher doses may be needed even following the exposure with the SARS–CoV-2 virus.
Next week, we will continue our discussion with how rheumatic disease patients who are infected with Covid respond with the use of conventional synthetic disease modifying antirheumatic drugs (csDMARDS).