Asthma Patients: Stay on Steroids in Face of COVID-19, Say Experts

Kate Johnson

March 20, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

With COVID-19 infections documented in every US state and clinicians waking up to the fact that this is everywhere, there is still lack of clarity on many basic points about the management of infection.

Although most people can be expected to recover at home without complications, patients with asthma are among those at risk for serious illness, according to the Centers for Disease Control and Prevention (CDC).

And people with asthma "have concerns about the steroids in their asthma inhalers weakening their immune system," notes the Asthma and Allergy Foundation of America (AAFA) website.

But asthma specialists are stressing that patients must keep using their preventive inhalers during this pandemic.

Optimal Control of Asthma Is First Defense Against Infection

"People with asthma need their [preventive] steroids," said Mitchell Grayson, MD, an allergist–immunologist at Nationwide Children's Hospital and chair of the medical scientific council for the AAFA. 

Michael Blaiss, MD, executive medical director of the American College of Allergy, Asthma & Immunology (ACAAI), echoed that advice.

"If a patient has asthma they need to stay on their preventive asthma medication, which in most cases would include inhaled corticosteroids," Blaiss, who is also clinical professor of pediatrics at the Medical College of Georgia in Augusta, told Medscape Medical News.

Optimally controlled asthma is the first weapon in the fight against the infection, other experts concurred.

"The last thing we want is patients stopping their asthma medicine and getting acutely ill," David Hill, MD, a pulmonary and critical care specialist in Waterbury, Connecticut, told Medscape Medical News.

"We don't want people coming to the hospital because they stopped adhering to their therapy out of fear that the therapy was going to cause a problem."

"If you have asthma and you are sick and you're bronchospastic and wheezing that's a reason to use steroids," stressed Hill, who is a spokesperson for the American Lung Association.

Concerns That Corticosteroids Worsen COVID-19

Part of the confusion is arising from reports of concerns about corticosteroid treatment in patients in general with lung involvement because of COVID-19 infection.

Advice for those in the general population infected with COVID-19 is that "corticosteroids are to be avoided" during treatment, according to the CDC as well as the World Health Organization.

This current consensus that there is no reason "to expect that patients [in general] with COVID-19 infection will benefit from corticosteroids, and they might be more likely to be harmed with such treatment," is also detailed in a Lancet commentary published last month.

This is because corticosteroids may "inhibit immune responses and pathogen clearance" of COVID-19, say the commentary authors, led by Clark D. Russell, MBChB, of the Centre for Inflammation Research, University of Edinburgh, UK.

And one of China's coronavirus experts has identified prolonged, high-dose corticosteroid use as a major risk factor for COVID-19 death.

"We conclude that corticosteroid treatment should not be used for the treatment of COVID-19–induced lung injury or shock outside of a clinical trial," say Russell and colleagues.

No Evidence That Staying on Steroids Worsens COVID-19 in Asthma

With regular influenza, not maintaining good symptom control is much more likely to result in patients with asthma being hospitalized, going to the ICU, and dying.

And there's currently no evidence to suggest the advice should be any different for COVID-19, say experts.

"The most important thing for an individual with asthma to avoid the complications of any viral respiratory infection, including COVID-19, is to maintain good control of their asthma," emphasized James Sublett, MD, past president of the ACAAI, and cofounder and chief medical officer of Family Allergy & Asthma, based in Louisville, Kentucky.

"We don't have any data that patients who stay on their preventive medication have more severe problems, more hospitalizations [with COVID-19]," said Blaiss.

Eric Macy, MD, an allergist–immunologist at Kaiser Permanente in San Diego, California, and a fellow of the American Academy of Allergy, Asthma & Immunology, agrees: "There are no data at this time that I am aware of that support an alternative plan."

Blaiss said that only the most severe asthma patients will be on oral corticosteroids anyway, "and with the advent of biologics, the vast majority switched."

"However, if patients are on oral corticosteroids with severe asthma [and COVID-19], they may want to check with their pulmonologist, but I would think the risk of not controlling the asthma is much more dangerous than being on the medication."

Pulmonologists in France, too, strongly emphasize that patients with asthma must continue treatment in the face of COVID-19. Those who are receiving inhaled or oral corticosteroid therapy should not interrupt it without the advice of their pulmonologist, or their attending physician, at the risk of exacerbating their illness, stress the French pulmonology society, Société de Pneumologie de Langue Française (SPLF), in a report today by Medscape France.

Pulmonologist Colas Tcherakian, MD, PhD, of Foch Hospital, Suresnes, France, said in a separate interview with Medscape France that, paradoxically, asthma does not always appear to be a significant risk factor for COVID-19, at least based on the experience so far in France — this may be due to the fact that background treatment is protective, he hypothesized.

So the answer as to whether to stop steroid treatment if you have asthma and are infected with COVID-19 is clearly "no", Tcherakian emphasized.

Not Everyone With COVID-19 Presents With Fever  

Allergist–immunologist Grayson also noted one particularly concerning observation in updated CDC guidance about presenting signs and symptoms of COVID-19 is that not all patients are febrile.

With the start of allergy season, this makes identification of COVID-19 especially challenging.

"What's scaring me is that only 44% are presenting to the hospital with fever. Cough, congestion, and rhinorrhea could be allergies — or it could also be COVID-19. I have no idea, and now they're standing in front of my nurses coughing in their faces — great," he told Medscape Medical News

"We were just discussing that in our office," agreed Hill. "Essentially, our message to patients is if you're not feeling well stay home. Normally when somebody's sick we want to see them but now we don't, so we're looking at telehealth options. And if they're really sick, the hospital has a special central area."

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