What are corticosteroids and how they are used in Lung Disease?
Corticosteroids, also sometimes referred to as just ‘steroids’, are an important type of medication in the treatment of many chronic lung diseases. In fact, they play a big role in both the chronic ‘controller’ treatment as well as in the acute ‘rescue’ treatment during sudden attacks or flare-ups known as exacerbations. This class of drug can be used locally, as is the case when puffers are used for the lungs (inhaled corticosteroid, ICS). It can also be used systemically to act on the whole body – this is the case when it is given either orally (oral corticosteroid, OCS) or intravenously.
Corticosteroid use in light of COVID-19
The main effectiveness of the corticosteroid drug class stems from the fact that these medications are very good at reducing inflammation, which can be harmful to the body. In doing so, however, one of the side effects of corticosteroids is that the body’s own immune system is an innocent bystander and becomes less able to fight off certain infections.
This delicate balance between harm versus benefit is actively considered every time you are prescribed this type (and for that matter, any type) of treatment by your healthcare provider. There have been situations where the potential harms of steroids were thought to outweigh their treatment effects during the current COVID-19 pandemic. In such cases of risk > benefit, the benefit may not yet be proven, or there may be no benefit in which case any side effects from the drug would introduce only harm without benefit.
One important example is when deciding how to treat all people in the general population affected by COVID-19 (even those without any underlying chronic lung disease). Using corticosteroids non-specifically here, to target lung injury caused by the SARS-CoV-2 virus, does not appear to be beneficial1 and is not recommended by the World Health Organization (WHO) when it is just for the sake of treating SARS-CoV-2 virus pneumonia.2
Given this information, in the COVID-19 affected world we now find ourselves, this may raise a number of very rational and reasonable questions from our readers living with chronic lung conditions:
Should I Continue My ICS-Containing Controller Inhaler During The COVID-19 Pandemic? If I Get Sick Enough To Need The OCS In My Action Plan, Should I Take It?
The experts at the Canadian Thoracic Society (CTS) have reviewed the relevant studies to date that pertain to the different roles of steroids in COPD and asthma during the COVID-19 pandemic. The results are explored below.
Chronic Obstructive Pulmonary Disease (COPD)
Depending on the individual patient, in addition to bronchodilators which dilate narrowed airways, the chronic care of COPD can include treatment with ICS-containing inhalers on a daily basis. ICS is typically added to long-acting bronchodilators in those patients who experience frequent exacerbations.3-5 Bloodwork biomarkers such as the level of eosinophils in the blood can also help guide this decision.3,4,6 During the COVID-19 pandemic, experts at the CTS recommend that patients with COPD on chronic ICS controller therapy continue their ICS therapy.7 The rationale is that, in the absence of studies showing any clear benefit or harm from ICS use in patients affected with COVID-19, and with a lot of evidence for its benefit in carefully selected patients with COPD, the best way to manage through this pandemic for patients with COPD is to have their condition as well-controlled as possible. Because ICS use in specific patients with COPD can reduce exacerbations, keeping ICS therapy going can help avoid the need for emergency department visits and/or hospitalizations.
The CTS recommend that patients with COPD on chronic ICS controller therapy continue their ICS therapy.
An Action Plan is an effective written guide that is provided along with education to patients with COPD in order to recognize early exacerbation symptoms and to act in starting early exacerbation treatment.8 OCS is typically a central part of an Action Plan; it is also used in treating those exacerbations needing hospitalization. The experts at the CTS recommend that, if needed, OCS should be used during an exacerbation – whether or not it was triggered by the SARS-CoV-2 virus.
Asthma is typically characterized by chronic airway inflammation, and it is for this reason that ICS is the fundamental cornerstone of effective asthma control.9,10 Indeed, the role of ICS is so important in asthma that we are starting to see a growing trend away from ever treating with just short acting bronchodilator puffers (even in ‘rescue’ situations) in favour of using ICS-containing puffers for both ‘controller’ and ‘rescue’ treatment.9,11 After reviewing the relevant studies so far, the CTS experts concluded that it does not appear that patients with asthma have an increased risk of catching the SARS-CoV-2 virus.7 They recommend that, like in patients with COPD, patients with asthma should continue usual ICS-containing therapy as it has been prescribed. If they need it, OCS should be used for a severe asthma exacerbation – whether or not it was triggered by the SARS-CoV-2 virus.
The CTS experts concluded that it does not appear that patients with asthma have an increased risk of catching the SARS-CoV-2 virus
The bottom line
The bottom line (at the time of writing) for our readers with asthma and COPD: If you usually take controller ICS – continue it under ongoing monitoring of your doctor; if you are unwell enough to need OCS – take it if your doctor has prescribed it and has counselled you to do so. If you have any concerns regarding the risks and benefits of steroid-containing treatments – ask your healthcare provider for guidance.
About the author
Bryan completed his medical school and Internal Medicine residency at the University of Toronto, and his Respirology fellowship at the University of Alberta. Prior to this he completed his undergraduate degree at Queen’s University and his master’s degree in Physiology at McGill University. He has had a longstanding clinical and research interest in respiratory and cardiac physiology and applied exercise science, in pulmonary rehabilitation, and in the management of chronic respiratory disease. He is currently completing an additional fellowship at the Montreal Chest Institute (McGill University Health Centre) in pulmonary rehabilitation and chronic disease management.