Corticosteroids for Non-severe COVID-19: Primum Non Nocere.

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.

Sir,

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.