Inhaled Corticosteroids and COVID-19: a Systematic Review and Clinical Perspective

Halpin DMG, Singh D, Hadfield RM. Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective. Eur Respir J. 2020;55(5):2001009. Published 2020 May 7. doi:10.1183/13993003.01009-2020

The current coronavirus 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection, raises important questions as to whether pre-morbid use or continued administration of inhaled corticosteroids (ICS) affects the outcomes of acute respiratory infections due to coronavirus. Many physicians are concerned about whether individuals positive for SARS-CoV-2 and taking ICS should continue them or stop them, given that ICS are often regarded as immunosuppressive. A number of key questions arise. Are people with asthma or COPD at increased risk of developing COVID-19? Do ICS modify this risk, either increasing or decreasing it? Do ICS influence the clinical course of COVID-19? (figure 1). Whether ICS modify the risk of developing COVID-19 or the clinical course of COVID-19 in people who do not have lung disease should also be considered (figure 1).

COVID-19 has an initial period characterised by cough and fever, followed by the development of dyspnoea after around 8 days in ∼20% of patients, with pulmonary infiltrates in about 10% [1, 2]. Approximately 25% of patients admitted to hospital developed acute respiratory distress syndrome (ARDS) a median 10.5 days after symptom onset [2].

In vitro models suggest that there is impaired interferon production and other antiviral innate immune responses to experimental rhinovirus and influenza infection in both asthma and COPD, and this could potentially increase susceptibility to viral infections including COVID-19. However, not all studies have replicated these findings [3]. For instance, a study of the response of asthmatic children to natural colds, including some due to coronavirus, showed an appropriate innate response [4]. These contrasting results may reflect the heterogeneity in innate immune responses between individuals and/or variability in the response to different viruses [5].

Surprisingly, the prevalence of chronic respiratory disease among patients with SARS and COVID-19 appears to be lower than among the general population [6]. This is not the case for other chronic diseases and leads us to hypothesise that lung disease, patients’ behaviour or, more likely, their treatment may have some protective effect. Sadly, patients with underlying lung disease who develop COVID-19 and are hospitalised have worse outcomes, with a case fatality rate of 6.3% compared to 2.3% overall in China [7].

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