Some American Doctor are Now Treating Steroids Like Medical Malpractice Even for Non COVID Disorders

[McCamy Taylor]

Last edited Wed Apr 1, 2020, 04:38 AM - Edit history (2)

Not kidding. Know a couple of asthmatics who know that they require a short course of steroids to keep them out of the hospital who can not get steroids due to "Everyone knows" that steroids in COVID will kill you. I have heard this twice in the past week so I decided to investigate to see where is this general wisdom coming from.

It isn't coming from this study in China:

https://www.medrxiv.org/content/10.1101/2020.03.06.20032342v1

Conclusion: Our data indicate that in patients with severe COVID-19 pneumonia, early, low-dose and short-term application of corticosteroid was associated with a faster improvement of clinical symptoms and absorption of lung focus.

Critique:This was a retrospective study not a prospective study. Possible reason for not using steroids---only one major contraindication uncontrolled diabetes. Since uncontrolled diabetes makes every infection worse, maybe the group that did not get steroids had an extra strike against them and the steroids for the other group did not do anything. On the plus side these were all classified as severe meaning the authors did not compare oranges to apples.

https://apps.who.int/iris/bitstream/handle/10665/331446/WHO-2019-nCoV-clinical-2020.4-eng.pdf

OK ,here are some recent guidelines for COVID management. Note that the findings are based upon studies of SARS and MERS and Influenza, not COVID. Note that these are observational studies--that means they looked at people who were selected to receive steroids and compared them to those who were not. Now, image that a steroid dependent asthmatic got SARS. Yes, of course they would have gotten steroids. Lots of steroids? Could their underlying lung disease have led to a worse outcome? You tell me. The studies listed below do not.:

Remark 1: A systematic review of observational studies of corticosteroids administered to patients with SARS reported no
survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance) (62). A systematic
review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the
evidence was judged as very low to low quality due to confounding by indication (63). A subsequent study that addressed this
limitation by adjusting for time-varying confounders found no effect on mortality (64). Finally, a recent study of patients receiving
corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed lower
respiratory tract (LRT) clearance of MERS-CoV (65). Given the lack of effectiveness and possible harm, routine corticosteroids
should be avoided unless they are indicated for another reason. Other reasons may include exacerbation of asthma or COPD,
septic shock, and risk and benefit analysis needs to be conducted for individual patients.

Here is the conclusion of study 62 above:

https://www.ncbi.nlm.nih.gov/pubmed/16968120

In 29 studies of steroid use, 25 were inconclusive and four were classified as causing possible harm.

CONCLUSIONS:
Despite an extensive literature reporting on SARS treatments, it was not possible to determine whether treatments benefited patients during the SARS outbreak. Some may have been harmful. Clinical trials should be designed to validate a standard protocol for dosage and timing, and to accrue data in real time during future outbreaks to monitor specific adverse effects and help inform treatment.

25 inconclusive and 4 possible harm adds up to be inconclusive, not definitely will kill you.

Maybe the evidence in the next study is more compelling
Here is citation 63

https://www.ncbi.nlm.nih.gov/pubmed/26950335

AUTHORS' CONCLUSIONS:
We did not identify any completed RCTs of adjunctive corticosteroid therapy for treating influenza. The available evidence from observational studies is of very low quality with confounding by indication a major potential concern. Although we found that adjunctive corticosteroid therapy was associated with increased mortality, this result should be interpreted with caution. In the context of clinical trials of adjunctive corticosteroid therapy in sepsis and pneumonia that report improved outcomes, including decreased mortality, more high-quality research is needed (both RCTs and observational studies). Currently, we do not have sufficient evidence in this review to determine the effectiveness of corticosteroids for patients with influenza.

That is not compelling at all.

Moving on to 64.

https://www.ncbi.nlm.nih.gov/pubmed/27036638

CONCLUSIONS:
Corticosteroids were commonly prescribed for H1N1pdm09-related critical illness. Adjusting for only baseline between-group differences suggested a significant increased risk of death associated with corticosteroids. However, after adjusting for time-dependent differences, we found no significant association between corticosteroids and mortality. These findings highlight the challenges and importance in adjusting for baseline and time-dependent confounders when estimating clinical effects of treatments using observational studies.

Hmm. So, depending upon which line you read, steroids either kill you--or they don't.


Citation 65

https://www.ncbi.nlm.nih.gov/pubmed/29161116

CONCLUSIONS:
Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.

And then 66 a paper reviewing the use of steroids for sepsis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083439/

Sepsis is a syndrome of life threatening infection with organ dysfunction, and most guidelines do not advise use of corticosteroids to treat it in the absence of refractory shock

Two new trials of corticosteroid treatment for sepsis came to differing conclusions

Corticosteroids may reduce the risk of death by a small amount and increase neuromuscular weakness by a small amount, but the evidence is not definitive

This guideline makes a weak recommendation for corticosteroids in patients with sepsis; both steroids and no steroids are reasonable management options

More (not) compelling evidence

https://jamanetwork.com/journals/jama/article-abstract/2763879

In adults receiving mechanical ventilation who do not have ARDS, routine use of systematic corticosteroids is suggested against (weak recommendation, LQE). In those with ARDS, use of corticosteroids is suggested (weak recommendation, LQE).

Here the Lancet sums up all the ways that steroids with COVID will (not) kill you:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30317-2/fulltext

No clinical data exist to indicate that net benefit is derived from corticosteroids in the treatment of respiratory infection due to RSV, influenza, SARS-CoV, or MERS-CoV. The available observational data suggest increased mortality and secondary infection rates in influenza, impaired clearance of SARS-CoV and MERS-CoV, and complications of corticosteroid therapy in survivors. If it is present, the effect of steroids on mortality in those with septic shock is small, and is unlikely to be generalisable to shock in the context of severe respiratory failure due to 2019-nCoV.

The word that jumped out at me was "survivor". I would much rather have a steroid side effect and be alive than die with strong bones.

It is going to be close to impossible to do a study about the risk/benefits of steroids for COVID. Those who are already on steroids when they get sick are likely to have asthma or be immune suppressed--increasing their risk for severe disease.

But please, can we stop punishing those who actually need their steroids to breathe by saying "In this climate, I am not prescribing steroids"? It makes it sound like health care providers are more concerned about not getting sued than about treating individual patients for their individual needs.

[pat_k]

1. Links to reports that corticosteroids, glucocorticoids, and other therapies are being withheld? (nt)

[McCamy Taylor]

2. Anecdotal only. Two people with asthma told that their doctors

Are no longer prescribing steroids due to COVID. Wanted to see why they were concerned but I cannot find compelling evidence either way. If someone knows of a good study that proves danger please post a link.

[pat_k]

5. Reason enough to watch for a trend.

But perhaps not enough to assume widespread trend.

But should be investigated in whatever way possible. Whenever a useful, or even vital, medication gets a "bad wrap" for one reason or another, it is a serious problem. (e.g., Detroamphetamine is often more effective for ADD but somehow Psydocs are reluctant to prescribe, and instead go with Adderall, which has more side effects and raises heart rate more.)

On a different front, at the moment, I'm slightly worried about the delay in filling my Hydroxychloroquine (for Rheumatoid arthritis). I can't imagine that there really has been such a "run" on it that supplies are low, but the refill was due to be ready two days ago. . .

[JCMach1]

3. I just finished a round for gout in my toe

A few days back. A teladoc prescribed as I absolutely did not want to find myself in an ER for severe gout attack

[A HERETIC I AM]

4. I'm on a multi-day tiered course of 10mg tabs right now.

I am having the first COPD episode I've had in almost 2 years, but I have no other symptoms of COVID, just shortness of breath.

It feels just like the dozen or so other COPD attacks I've had over the last 7 or 8 years.

4 tabs for 3 days, 3 tabs for 3 days, 2 for 3, etc.

Got them Sunday afternoon. They have stopped the progression, as I was getting worse by the day, but here on Wednesday morning I am no worse than I was Sunday morning.

Of course, having the first episode in 2 years right now? Damn, but could the timing possibly get any worse?

I need to stay out of the hospital, so if it doesn't improve, a shot of Solu-Medrol will be next, I'll bet. Hopefully it won't come to that and the pills will open me back up again. I'm also using a nebulizer with a "Duo Neb" of Albuterol Sulfate and Ipratropium bromide.