Coronavirus Disease 2019 and Pediatric Asthma: Friend or foe?

Elissa M. Abrams


Curr Opin Allergy Clin Immunol. 2022;22(2):95-100. 

In This Article

Asthma Medications and Coronavirus Disease 2019 Risk

Inhaled corticosteroids

The impact of inhaled corticosteroids (ICS) therapy on COVID-19 outcomes is unclear. A meta-analysis of 39 trials (N = 11 615 children with asthma) on ICS use does not support an increased risk of respiratory infection in general.[27] A statement from the EAACI notes that 'since asthma itself may be a risk factor for the severity of COVID-19 disease and since the use of ICS does not pose an increased risk for pulmonary or systemic infections in children with asthma, their regular use is unlikely to increase the risk of acquiring the infection or increasing the severity of the present infection'.[11]

There is a pathophysiologic basis to the possibility that ICS use may reduce risk of severe COVID-19 outcomes. ICS use has a beneficial impact on pulmonary physiology and reduces the risk of acute respiratory distress syndrome.[28] Studies (although not specific to the pediatric population) have found ICS therapy to reduce ACE2 pulmonary expression, which has the potential to reduce susceptibility to SARS-CoV-2 infection and severe COVID-19 infection,[29] although to what extent this impacts real-world clinical outcomes remains unclear.[30] In addition, Inhaled ciclesonide has been shown in vitro to suppress SARS-CoV-2 replication in cultured cells potentially due to antiviral in addition to anti-inflammatory activity, although to date no clinical trials have examined the use of ICS in COVID-19.[31] A systematic review of whether use of ICS is a risk factor for adverse outcomes due to COVID-19 (not specific to the pediatric population) found that, among 59 publications, there was no evidence on whether ICS use is a factor for adverse or beneficial outcomes in acute respiratory infections due to coronavirus infection.[32] Studies are ongoing but it has been noted that while it is unknown whether ICS protects against COVID-19, 'to dismiss this hypothesis…is premature'.[28]

The Global Initiative for Asthma (GINA) strategy, as well as the American Academy of Allergy, Asthma and Immunology (AAAAI) recommend remaining on ICS therapy during the pandemic.[33,34] Nebulization should be avoided if possible as it is aerosol generating.[35,36] Remaining on ICS therapy is essential for asthma control, and any reduction or taper in dosing carries the risk of asthma exacerbations, ED visits, and/or a need for oral corticosteroid (OCS) use.[26] In fact, it has been suggested that even in a child for whom asthma is very well controlled, and in whom ICS dose reduction would be considered, greater caution should be exercised and could be based on atopic status and baseline risk.[26] As noted by the AAAAI, the 'optimal control of asthma symptoms is the first defense against COVID-19'.[33]

Oral Corticosteroids

As with ICS, the impact of OCS therapy on COVID-19 outcomes remains unknown. There is little to no evidence in the pediatric population and evidence is evolving in the adult asthma population. A large study based on primary care records in the United Kingdom found that, among adults, the risk of COVID-19 death was increased among those who had recently needed OCS therapy for asthma.[37] In a study of 8242 adults with asthma, OCS therapy was associated with a significantly increased risk of moderate-to-severe COVID-19, as well as all-cause mortality within 90 days (although not associated with increased risk of SARS-CoV-2 infection).[38] In addition, with previous coronavirus epidemics such as SARS and Middle Eastern Respiratory Syndrome, OCS use was associated with reduced viral clearance.[39] The CDC notes that due to the immunosuppressive effects of OCS therapy, using OCS does place individuals at higher risk of severe COVID-19 outcomes.[40] However, overall, a systematic review and meta-analysis (total 1703 adult patients) noted administration of systemic corticosteroids compared with usual care reduced 28-day all-cause mortality among those critically ill with COVID-19 (although used as a COVID-19 treatment and not specific to asthma).[41] The GINA strategy recommends that while minimizing the use of OCS therapy is important, OCS therapy should be considered in those with severe asthma and could be used for a short course for a severe asthma exacerbation during the pandemic.[34]

Biologic Medications

Current recommendations are to remain on asthma biologic medications during COVID-19, other than the possible exception of suspension of biologic medications during an acute phase of a COVID-19 infection.[11,42] The AAAAI has stated that there is no evidence that the immune response to COVID-19 will be impaired in patients with asthma on biologic therapies and that it would be 'reasonable' to continue administration of biologics in patients with asthma.[33,43] This recommendation is supported by several international allergy/pulmonology organizations including the British Thoracic Society.[44,45] The GINA strategy similarly supports remaining on biologic medications.[34]

There are no studies specific to COVID-19 outcomes in children and adolescents on biologic therapy during COVID-19. There is some limited evidence in the adult asthma population that use of biologics is not associated with a higher risk of COVID-19 infection or severe outcomes. For example, a prospective study of 676 adults with severe asthma on biologic therapy found a low incidence of COVID-19 infection (2.1%) among patients with severe asthma, and only 5% presented COVID-19-related symptoms.[46] In a cohort study of 8242 patients with asthma who tested positive for SARS-CoV-2 infection, biologics were not an increased risk of SARS-CoV-2 infection, nor with a significantly increased risk of moderate-to-severe COVID-19 infection, nor with the composite end point of moderate-to-severe COVID-19 or all-cause mortality within 90 days.[38]

Home-based administration of biologics has emerged as an option during COVID-19. A study of 23 children with asthma on biologic therapy noted that home administration of omalizumab and mepolizumab, virtually supported by video calls and home spirometry, was safe and accurate without any significant adverse events.[47] In addition, it was positively perceived by children and their caregivers. At-home administration of omalizumab or mepolizumab has been demonstrated to be a cost-effective strategy.[48] Multiple international organizations support home-based administration of biologics when possible during the pandemic.[43,48,49]