Steroids help COVID-19 death rates, but not all
New studies show that treating critically ill COVID-19 patients with inexpensive steroids can cut their risk of dying from the illness by a third. The results are so clear that the World Health Organization changed its advice on Sept. 2 and now strongly recommends corticosteroids as a first-line treatment for the sickest patients.
Steroids aren't riskfree, however. They can have side effects, and they could do more harm than good in patients with milder cases of COVID-19.
I am a pulmonologist and critical care physician and co-author of one of three new studies that analyzed data from clinical trials involving the effect of steroids on thousands of critically and severely ill COVID19 patients. Here's what people need to understand about steroids as a treatment for COVID-19.
Who benefits from taking steroids?
It's important to understand that steroids can benefit the sickest patients hospitalized with COVID-19, but they're not a treatment for relatively mild cases.
With COVID-19 and other infectious diseases, there are two key components: the infection itself and the body's response to that infection.
In the sickest patients, the body's immune system response is so robust it can injure organs. So, calming the immune response may be important. But someone who is less severely ill may need the body's immune response to prevent the infection from getting worse. You wouldn't want to interfere with the immune response unless it was harming the patient.
How do corticosteroids help critically ill patients?
When an infection triggers an inflammatory response, specialized white blood cells are activated to go find the virus or bacteria and destroy it. It's more of a bomb effect than a targeted missile strike – the immune cells attack broadly, and the inflammation created can damage other cells in the vicinity.
That response can get out of control and continue even after the infectious agent is gone. In a really exuberant immune response, the patient can have respiratory failure and end up on a ventilator, or have circulatory failure and end up in shock, or they could develop kidney failure from the shock.
In patients with severe COVID-19, corticosteroids are likely able to calm that inflammatory response and prevent the progression of organ damage, potentially in the lungs.
Scientists aren't yet certain that that is how steroids are working. What we do know from the new studies is that people with severe COVID-19, particularly those with respiratory complications, benefit from relatively low-dose courses of corticosteroids. A combined analysis of the recent studies found the death rate four weeks after infection was significantly lower in patients with severe COVID-19 who received steroids than those who did not.
Why does the WHO recommend not using steroids for cases that aren't severe?
No treatment comes without risk.
Steroids are well-known immune-suppressing medications that have been used for decades. They're commonly used for treating chronic diseases that are inflammation-related, like asthma, or autoimmune disorders such as lupus or rheumatoid arthritis. But there may be consequences.
The potential harms from using steroids in a hospital include an increased risk of bacterial or fungal infections, hyperglycemia, acquired muscle weakness and gastrointestinal bleeding.
For people with milder cases of COVID-19, taking steroids could mean increasing their risks little potential benefit.
Taking steroids long-term also carries other risks, including predisposition to infection and developing osteoporosis, cataracts and glaucoma. So, to take steroids as a potential preventive measure against COVID-19 could come with significant potential risk to otherwise healthy people.