Asthma, Severe Acute Respiratory Syndrome Coronavirus-2 and Coronavirus Disease 2019

Dylan T. Timberlake; Kasey Strothman; Mitchell H. Grayson


Curr Opin Allergy Clin Immunol. 2021;21(2):182-187. 

In This Article

Asthma Therapeutics

Early during the COVID-19 pandemic concerns arose about the use of corticosteroids in infected patients. Previous studies of SARS-CoV found that the early use of corticosteroids increased plasma viral load and prolonged the time until viral clearance, but it was unclear if this was true for SARS-CoV-2.[45] A retrospective study performed early in the COVID-19 pandemic found that patients who were admitted with and died from COVID-19 were significantly more likely to have received high-dose corticosteroids.[46] These data, amongst others, led the WHO in March 2020 to recommend against 'routinely giving systemic corticosteroids for treatment of viral pneumonia (in COVID-19) outside clinical trials.'[47,48] This statement and the resulting publications, along with the well-described immunosuppressant effects of steroids, led patients with asthma to have concerns that the use of their inhaled corticosteroids (ICS) could increase their risk for severe outcomes from COVID-19.[49]

Data regarding asthma therapeutics in COVID-19 are extremely limited, with a systematic review performed in May 2020 of ICS and COVID-19 finding no evidence to support asthma patients discontinuing ICS use.[50] Subsequently, a study of asthmatic patients with a positive test for SARS-CoV-2 showed that ICS usage did not affect rates of hospitalization.[51] Although these data are limited, they do suggest that asthmatic patients requiring ICS therapy should continue on ICS therapy during the COVID pandemic to prevent worsening of their asthma control.

The impact of biologic medications on COVID-19 is also an important consideration, as their use for the management of asthma has been increasing, with a recent study of claims finding biologic medication use among asthmatics from 2017 to 2019 increasing from 3.3 to 5.8 users per 10,000 members.[52] Common biologics used in asthma include anti-IgE therapy with omalizumab, anti-Il-4 and anti-Il-13 therapy with dupilumab, and anti-Il-5 or anti-Il-5 receptor therapy with mepolizumab, reslizumab, and benralizumab.[53] With the role of inflammatory cytokines in severe disease with COVID-19, there is concern that immune modulation through biologic therapies may lead to altered severity of COVID-19 disease. Unfortunately, data regarding biologic therapies are extremely sparse. One case series described two asthmatic patients on benralizumab, both of which required admission but did not require intubation or a prolonged hospital stay.[54] A separate case report described one patient on omalizumab who required ICU admission but survived.[51] Thus, these data are extremely limited and cannot be used to guide medical decision making. It is somewhat reassuring that these patients did not have severe disease or higher mortality rates. Given the data available, the current recommendation would be to continue biologic therapy in those patients who require it for severe asthma, as maintaining good asthma control will decrease admission rates and decrease potential exposures to SARS-CoV-2.