LETTER TO THE EDITOR
Corticosteroids for Non-severe COVID-19: Primum Non Nocere
1–6Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Corresponding Author: Ritesh Agarwal, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 1722756825, e-mail: firstname.lastname@example.org
How to cite this article: Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN, Agarwal R. Corticosteroids for Non-severe COVID-19: Primum Non Nocere. Indian J Crit Care Med 2022;26(3):403–404.
Source of support: Nil
Conflict of interest: None
Keywords: Acute respiratory distress syndrome, Corticosteroids, COVID-19.
Subjects with coronavirus disease-2019 (COVID-19) may have a mild disease before developing a critical illness. Unfortunately, no laboratory markers consistently predict those who would worsen among the non-hospitalized individuals. Whether intervening at an early stage improves patient outcomes remains unknown. In this context, we were disheartened to see a statement from renowned experts recommending the use of glucocorticoids in non-severe COVID-19 illness.1 Contrarily, the living guidelines from World Health Organization (WHO) provides a weak recommendation against the use of glucocorticoids for non-severe COVID-19, based on a systematic review of the literature.2 Further, the WHO statement suggests erring on the side of not using glucocorticoids in those with symptoms more than 7 days, which is the focus of the current Delphi statement. Most importantly, the WHO recommends that more evidence be generated for using glucocorticoids in non-severe COVID-19 illness. Furthermore, there are data suggesting worse outcomes when glucocorticoids are used in patients with mild COVID-19.3
Clinical trials have relied on parameters such as SpO2 for guiding therapy, whereas the current recommendations suggest using inflammatory markers and repeating them after at least 3 days. Despite a pandemic affecting more than 257 million individuals worldwide, there is little evidence supporting the use of inflammatory markers to predict clinical worsening. The Delphi statement also suggests performing imaging, which would be unnecessary in patients with mild–moderate COVID-19.4 These recommendations will promote unnecessary investigations, add more to the financial burden and patient anxiety, and further strain the healthcare system, especially in resource-constrained settings. The experts have also ignored the raging epidemic of COVID-19-associated mucormycosis that occurred a few months ago, primarily attributable to inappropriate use of glucocorticoids in non-hypoxemic individuals that caused morbidity and mortality even in those with mild disease.5–7 Regardless, even a short course of glucocorticoid has significant metabolic and other adverse events and warrants a thorough justification of the indication.8
A Delphi statement is primarily indicated where there is a paucity of evidence. Such consensus statements are mostly guided by statistical trends observed in research studies enhanced by long and thoughtful clinical experience. However, there is sufficient evidence to suggest that glucocorticoids are unwarranted in non-severe COVID-19.9 The Delphi consensus on the use of glucocorticoids in non-severe COVID-19 was undoubtedly required to identify unmet research needs. However, such recommendations for clinical practice are undesirable.
Valliappan Muthu https://orcid.org/0000-0003-0410-8468
Inderpaul S Sehgal https://orcid.org/0000-0002-6505-6019
Sahajal Dhooria https://orcid.org/0000-0003-3199-9163
Kuruswamy Thurai Prasad https://orcid.org/0000-0001-7690-6595
Ashutosh N Aggarwal https://orcid.org/0000-0001-8556-3600
Ritesh Agarwal https://orcid.org/0000-0003-2547-7668
1. Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert consensus statements on the use of corticosteroids in non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280–1285. DOI: 10.5005/jp-journals-10071-23923.
5. Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (Covid-19) associated mucormycosis (CAM): case report and systematic review of literature. Mycopathologia 2021;186(2):289–298. DOI: 10.1007/s11046-021-00528-2.
6. Muthu V, Rudramurthy SM, Chakrabarti A, Agarwal R. Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world. Mycopathologia 2021;186(6):739–754. DOI: 10.1007/s11046-021-00584-8.
7. Patel A, Agarwal R, Rudramurthy SM, Shevkani M, Xess I, Sharma R, et al. Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India. Emerg Infect Dis 2021;27(9):2349–2359. DOI: 10.3201/eid2709.210934.
8. Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. British Medical Journal 2017;357:j1415. DOI: 10.1136/bmj.j1415.
9. Shuto H, Komiya K, Yamasue M, Uchida S, Ogura T, Mukae H, et al. A systematic review of corticosteroid treatment for noncritically ill patients with COVID-19. Sci Rep 2020;10(1):20935. DOI: 10.1038/s41598-020-78054-2.
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