Keep calm and carry on with steroids: living guidelines for COVID-19


By Michael Woodhead

5 May 2020

People with asthma or COPD who have COVID-19 disease should continue taking corticosteroids as prescribed and avoid stopping them, according to a consensus recommendation in Australia’s ‘living guidelines’ for COVID-19.

While acknowledging there is currently little available evidence about outcomes for inhaled or oral corticosteroids for patients with COVID-19 and asthma/COPD, the guidelines expert group concludes with the advice that clinicians should “use inhaled or oral steroids for the management of people with co-existing asthma or COPD and COVID-19 as you normally would for viral exacerbation of asthma or COPD.”

The recommendation is based on the rationale that stopping long-term inhaled or oral corticosteroids suddenly can lead to exacerbation of symptoms of asthma and COPD or risk of relative adrenal insufficiency.

“The panel believes that, while there is uncertainty about the benefits/harm ratio regarding the use of corticosteroids for COVID-19, there are likely harms associated with an exacerbation of COPD or asthma, as well as harms associated with a sudden stopping of corticosteroids, and thus patients may prefer to take steroids as prescribed,” the guideline says.

The recommendation is adapted from published recommendations from three clinical guidelines, including the Australian Asthma Handbook and the UK’s National Institute for Health and Care Excellence (NICE).

For patients with severe asthma, the Australian Asthma Handbook recommends that clinicians “administer or prescribe systemic (oral) corticosteroids to manage severe flare-ups or acute asthma as indicated, following recommendations based on age-group” but to be cautious using corticosteroids when acute viral infection is suspected or confirmed (e.g. avoid use for mild flare-ups).

For patients with asthma who are receiving inhaled steroids, the Australian Asthma Handbook also advises patients to continue taking inhaled corticosteroids. It reminds clinicians to warn patients that stopping their preventer increases the risk of severe asthma flare-ups, including those triggered by viral respiratory infections.

For patients with COPD, NICE recommends that patients who are having an exacerbation for COPD start a course of oral corticosteroids and/or antibiotics if oral corticosteroids and/or antibiotics are clinically indicated. Oral corticosteroids are not recommended for symptoms of COVID-19 alone (e.g. fever, dry cough or myalgia).

NICE also recommends continuing oral or inhaled steroids, and to avoid stopping or delaying withdrawal of inhaled steroids.

The ‘living guideline’ recommendation also notes the TGA advice that abrupt withdrawal of corticosteroids can lead to acute adrenal insufficiency or exacerbation of symptoms of asthma or COPD.

The advice also includes a recommendation not to use nebulisers.

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