A patient-tailored approach for corticosteroid treatment in COVID-19: still not there yet

Abstract

Three years after its first appearance, SARS-CoV-2 is still among the most troublesome respiratory viruses and the COVID-19 pandemic is still not under control globally. A clear association between dysregulated inflammation and adverse clinical outcomes has been demonstrated in COVID-19 since the very beginning of the pandemic with the so-called “cytokine storm” advocated as the key pathogenetic mechanism in severe disease. The scientific community theorized the use of immunomodulating agents to control this process and, among them, systemic corticosteroids have been extensively used during the pandemic since their first evidence in reducing mortality in June 2020 International guidelines unanimously report moderate-to-strong recommendations in favour of corticosteroids for hospitalised COVID-19 patients with acute respiratory failure (ARF) based on moderate-to-high quality evidence. Corticosteroids are not recommended for patients not requiring supplementary oxygen or for outpatients based on the absence of benefit in clinical trials. The standard regimen recommended by guidelines is oral or intravenous dexamethasone 6 mg once daily for 7–10 days. However, the last update of the UK NICE and US NIH guidelines provided some alternatives to dexamethasone, such as prednisolone 40 mg once daily, methylprednisolone 32 mg·day⁻¹ and hydrocortisone 150–160 mg·day⁻¹. These doses have been calculated according to the equivalent steroid potency, as dexamethasone has an anti-inflammatory effect 6.25 times greater than prednisolone, 5 times superior to methylprednisolone and 25 times more powerful than hydrocortisone. In addition, the latest guidelines developed by the European Respiratory Society (ERS) and the WHO identified the need to better evaluate the optimal corticosteroids to be used in COVID-19 in terms of formulation, dosage, timing, and scheme of administration.

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http://creativecommons.org/licenses/by-nc/4.0/ This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

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Identifiers

DOI

https://doi.org/10.1183/13993003.00270-2023

Repository URI

https://discovery.dundee.ac.uk/en/publications/2dc319f5-e954-4299-b427-46cfc6811d77