Warning of Higher COVID-19 Problems From Glucocorticoid Use

Peter Russell

Disclosures

April 11, 2020

Doctors should pay particular attention to patients with endocrine disorders and diabetes mellitus who develop COVID-19, endocrinologists said.

In an editorial published in the Journal of Clinical Endocrinology and Metabolism,  they say data from Wuhan province in China, where the pandemic started, suggested that patients with diabetes were over-represented in the group of people who become severely ill, and also among those who died.

Adults prescribed glucocorticoid therapy for common conditions, such as asthma,  and arthritis, as well as individuals with adrenal insufficiency, are at high risk for developing serious complications from COVID-19 due to an inability to mount a normal stress response, the authors said.

The endocrinologists have called on health professionals to be extra vigilant when dealing with patients in these categories.

Dr Paul Stewart

They said that while glucocorticoid treatment had no direct role to play in the treatment of COVID-19 patients, intravenous stress doses should be considered by doctors in patients treated with glucocorticoids for 3 months or more who were deteriorating with COVID-19.

We asked Dr Paul Stewart, editor-in-chief of the journal, and professor of medicine at the University of Leeds, to elaborate on the findings and the advice.

Q&A

Despite COVID-19 being a new phenomenon, do endocrinologists have an understanding of who the highest risk patients are?

I don't think anyone's immune from this.

So, this is an agent that probably, to be honest, is a very similar pathogen, if not actually slightly less infectious, than flu – influenza A – but the real issue here is that it's going through our community because none of us have ever been exposed to this before, so there's no inherent immunity.

Effectively, everybody's susceptible and as we're seeing, it's playing out differently, with some people just having a very trivial illness and some, for some reasons we don't fully understand, having a more severe illness.

We do know, however, that if you for whatever reason have been taking exogenous steroids treatment for inflammatory disease, then that has an effect on the immune system and you're more susceptible.

And we do also know that once infected, the people who appear to be over represented in terms of ICU admissions or sadly deaths, within there, there's an over representation, particularly of people with diabetes and high blood pressure.

Whether that's just a function of age, or whether it truly means that if you do have diabetes, you get a more severe illness, I think is yet to be ascertained.

You make the point that doctors need to pay particular attention to patients who are treated with glucocorticoids. Why this group in particular?

It's probably worth breaking that down into two groups.

There are people we know in our own practices as endocrinologists, who have problems because they can't make their own steroid hormones, usually disorders of a gland called the adrenal gland.

And we know about them, and they're replaced with steroid hormones – it's a kind of steroid replacement therapy – and they know if they do become unwell, one of the normal responses to mounting infection and overcoming infection is that we increase our own steroid levels in the blood in order to combat that infection. Of course, they can't do that so they know to take more in the event of any current infection.

The more worrying group, and the much larger group percentage wise – probably as much as 5% here of the 'at risk' population – are those people who are taking higher doses – exogenous doses of steroids – in order to treat underlying diseases such as asthma, such as inflammatory bowel disease, such as rheumatological conditions.

And we know that up to 50% of those have suppression of their own adrenal gland function. So, once they have enough steroid, often more than enough steroid, for their day-to-day living, the minute they become unwell, they too can't mount a normal immune response to the infection.

They're the ones we're particularly worried about because they're not under the care of endocrinologists, they're under the care of other doctors. But they might all have a common pathway in intensive care units where they might need steroid cover.

At a time of lockdown because of COVID-19, how has disruption of contact between patient and doctor affected these groups?

If you think of this in terms of prevention, you might prevent them deteriorating if there was, you know, as we put in the editorial, the kind of 'sick day rules' and those people have been able to increase their steroid dose.

That's the bit that might not be happening because of the prioritisation, quite rightly, for COVID-related patients.

The default response, I think, needs to be at intensive care units where this needs to almost be, as it is in Leeds, a policy that people that have been on steroids in excess of 3 months needs to be regarded as high risk.

And you've always got in the back of your mind that possibility that they might need supplemental steroids. This isn't giving steroids to treat the underpinning COVID because, if anything, we know that that's probably not the right thing to do, but this is treating the underlying adrenal problem that the exogenous steroids have caused. 

If any doctor or healthcare professional is coming across people who received steroid therapy for the previous 3 months, they need to be regarded as an 'at risk' individual in terms of the progression of their illness, with a fairly low threshold for giving them supplemental steroid therapy, which might be life saving. That's the plea here.

Our Response to COVID-19 as Endocrinologists and Diabetologists. Ursula B Kaiser, Raghavendra G Mirmira, Paul M Stewart. The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 5, May 2020, dgaa148, https://doi.org/10.1210/clinem/dgaa148

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