In some people, COVID-19 causes mild or no symptoms at all. In others, it can cause significant respiratory distress that can lead to death. Once infected with COVID-19, is there anything that someone can do to foster a less severe infection? The answer is likely “yes,” avoid the use of outpatient steroids.
The risk factors for a poor outcome with COVID-19 include age over 65, obesity, diabetes, and a compromised immune system. By looking at the use of steroids, we can influence this fourth critical factor. Steroids come in two categories: anabolic and catabolic. Anabolic steroids such as testosterone and growth hormone promote building muscle and bone. Catabolic steroids such as prednisone and methylprednisolone promote muscle and bone loss, suppress the immune system, and impair healing. Thus, treating mild cases of COVID-19 with steroids may allow the virus the spread more extensively while impairing the body’s ability to heal itself from the infection.
For example, Frank M.is a 48-year-old male who runs a chain of family-owned convenience stores who tested positive for COVID-19 two weeks earlier. Frank had mild symptoms, so he continued to work from home. However, after two weeks of a nagging dry cough, his outpatient provider gave him an antibiotic, an intramuscular shot of steroids, and oral steroids to take at home. Within 72 hours of receiving the steroids, Frank ended up in the Emergency Room, and I admitted him for respiratory distress. He required increasing supplemental oxygen for over a week before improving. Because Frank and a handful of other patients did not have the usual comorbid conditions associated with a severe case of COVID-19, I began asking all of my patients in the hospital whether they had received steroids as an outpatient. It turns out that in patients under 55 years-old without comorbidities, over 91 percent of them received steroids as an outpatient.
After reviewing the medical literature, large trials have not focused on the use of outpatient steroids. Frank may have been improving when his provider tried steroids to suppress an annoying dry cough. These steroids may have suppressed the cough as well as suppressing his immune system, which allowed the virus to replicate and spread itself further. Additionally, steroids may have hampered his lungs’ ability to heal themselves, which may have prolonged his course combatting COVID-19. The medical literature is still evolving in the treatment of COVID-19, but it does not support using outpatient steroids alone or in combination with an antibiotic.
So, why do we use steroids at all with COVID-19? In the early days of the pandemic, treatment options, including steroids, were hypothesized since the virus may cause a significant inflammatory response. Since the immune system damages the virus and our own tissue, decreasing the immune system may theoretically decrease damage to our lungs. However, the opposite hypothesis may also be true: steroids may allow greater spreading of COVID-19 within the body and reduce the body’s ability to heal itself. Thus, steroids in the outpatient setting may act to turn a mild infection into a more severe one.
The RECOVERY Collaborative Group published a study in the New England Journal of Medicine looked at steroids’ efficacy in hospitalized patients. While the study showed some benefit for patients who require mechanical ventilation/life support, it showed harm to those who did not require supplemental oxygen. Likewise, the CDC does not recommend using outpatient steroids in the setting of a COVID-19 infection. Yet, steroids are used with worrisome frequency for COVID-19 in the outpatient setting.
The medical literature takes years to collect enough data for a definitive answer. However, individuals must make decisions today. Based on the available data and my clinical experience, I would suggest avoiding outpatient steroids whenever possible. When treating COVID-19 as an outpatient, patients should carefully discuss any possible use of steroids with their physician.
William Mazzella is an internal medicine physician.
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