"High" dose of steroids in mild infection may lead to viral pneumonia?

[Wrichik Basu]

This is again based on what was said by the Director of AIIMS in a press conference. He said that many people are self-medicating, and taking high dose of steroids even in mild COVID infection, which increases viral multiplication and leads to viral pneumonia. From this new article,

"Some patients take steroids in the early part of the disease which increases viral replication. Taking high dose steroids in mild cases may lead to severe viral pneumonia. Steroids should be taken in moderate stage and as advised by doctors," he said.

Two questions on this:

1. What does "high" mean? Can 0.5 mg budesonide taken as nebulizer once everyday be considered "high"? Or is 12 mg methylprednisolone two times a day "high"? I know this will vary from person to person, but I am just asking for an estimate.

2. Steroids are basically anti-inflammatory. How do they help in viral replication?

I am asking these because we all know how bad viral pneumonia can be. (One of our relatives passed away today after suffering from viral pneumonia caused by COVID.) People who have COPD are often prescribed steroid inhalers by doctors. Mom, for instance, takes an inhaler which contains budesonide and formoterol (the latter being a bronchodilator).

 

[pinball1970]

This is again based on what was said by the Director of AIIMS in a press conference. He said that many people are self-medicating, and taking high dose of steroids even in mild COVID infection, which increases viral multiplication and leads to viral pneumonia. From this new article,

Two questions on this:

1. What does "high" mean? Can 0.5 mg budesonide taken as nebulizer once everyday be considered "high"? Or is 12 mg methylprednisolone two times a day "high"?

2. Steroids are basically anti-inflammatory. How do they help in viral replication?

I am asking these because we all know how bad viral pneumonia can be. (One of our relatives passed away today after suffering from viral pneumonia caused by COVID.) People who have COPD are often prescribed steroid inhalers by doctors. Mom, for instance, takes an inhaler which contains budesonide and formoterol (the latter being a bronchodilator). If she ever contracts COVID, will this inhaler become dangerous for her?

Im very sorry for your loss.

One of the mentors may consider this a medical advice question probably @berkeman can respond?

 

[Wrichik Basu]

One of the mentors may consider this a medical advice question

The last question may be considered medical advice, and in that case, ignore it (I have edited the OP accordingly).

 

[pinball1970]

HiI have been prescribed steroids for asthma during a bad episode that required a short stay in hospital

Some info on that drug here – they reduce inflammation in the lungshttps://www.nhs.uk/medicines/prednisolone/
As far as I know, topical application steroids like hydrocortisone cream are used as an anti inflammatory for things like acne and eczema

As inflammation is part of the immune response oral steroids will impact on the immune system as a whole/systemically ie response to infection

So while oral steroids could help with the lung inflammation they could possibly impede the immune response to the microbes that caused infection in the first place. EDIT: Or opportunistic pathogens, viral and bacterial

@jim mcnamara @BillTre are best on this probably, I could google but my knowledge is sketchy and info was sketchy to asthmatics at the beginning of the pandemic regarding oral steroids

Advice was masks and isolation, not much on drugs apart from making sure we did not run low/out

 

[Wrichik Basu]

As inflammation is part of the immune response oral steroids will impact on the immune system as a whole/systemically ie response to infection

So while oral steroids could help with the lung inflammation they could possibly impede the immune response to the microbes that caused infection in the first place.

I was thinking too that probably this was aimed at oral steroids rather than inhaled steroids. Oral steroids have a greater degree of absorption in the body compared to inhaled ones.

 

[Ygggdrasil]

2. Steroids are basically anti-inflammatory. How do they help in viral replication?

I can't speak to the specific effects of the steroid drugs mentioned, but in general, the inflammatory response is a normal part of our body's reaction to pathogens and is supposed to help our body clear viral infections. Furthermore, many steroidal drugs are immunosuppressants (such as dexamethosone, which in clinical trials has been shown to reduce mortality among people with severe COVID-19), so while helpful at later stages of the disease, these drugs can hinder immune responses to the virus if administered too early.

To understand why immunosuppressants can be harmful if administered early but helpful if administered later, it is helpful to divide the course of the infection into roughly two phases. In the early phase, most of the damage to the body is done by the virus. During this stage, there is a race between the body and the virus, where the body is trying to mount an effective immune response to contain the virus before the virus can become too widespread. Things like antiviral drugs (like remdesivir) that slow viral replication or vaccines (which give the body a head start on establishing an adaptive immune response) are helpful here. Many older people have weaker immune systems, which is why younger people tend to contain the virus while experiencing only mild sympoms while older people and others with suppressed immune systems are at greater risk of severe disease and death.

If the body's immune response fails to contain the virus, the infection progresses to more severe stage where much of the damage from the disease now is not coming from the virus, but due to the body's response to the virus (the "cytokine storm"). It's at this stage where the effective treatments include many immunomodulatory drugs, including immunosuppressant corticosteroids like dexamethosone. These drugs help tame the cytokine storm to prevent potentially fatal damage to the body's organ systems.

Thus, while immunosuppressant drugs are helpful in the later, more severe stages of the disease, it is likely that immunosuppressants are harmful if administered too early. These drugs may make people with mild disease, who would have been able to fend of the infection just fine without treatment, progress to more severe disease because of the immunosuppressant effects of the steroid drugs (indeed some studies have shown that coricosteroids might delay virus clearance, and corticosteroids seem to lead to worse outcomes for influenza, a similar respiratory virus). The US National Institutes of Health recommends starting therapy with dexamethosone only in hospitalized patients who require supplemental oxygen.

For more information see:
NIH COVID-19 treatment guidelines
https://www.covid19treatmentguidelines.nih.gov/immunomodulators/corticosteroids/
https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/

A letter published in a scientific journal disucssing the right time to administer corticosteroids:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337659/

 

[Wrichik Basu]

Not related to the main topic of this thread, but I had one question: Can very low doses of anticoagulants (low molecular weight heparins like enoxaparin or rivaroxaban) be helpful to COVID patients if administered at an early stage, or will they do more harm than good and should be administered when the infection becomes more severe?

 

[jim mcnamara]

A hallmark of Covid-19 infection is microthrombii forming in the vessels surrounding the alveoli. It is evident as one of the differences in autopsy between influenza and Covid-19.

So, if there is clotting in "all the wrong places", anti-coagulants help to prevent that. But. Massive doses can cause GI bleeding, for example. Obviously this is a not good side effect. So this becomes an effort to prescribe an anticoagulant dose with beneficial effects -- but without harming the patient.

Does that answer your question - one dose does not fit all patients - like many things biological?

 

[Wrichik Basu]

Does that answer your question - one dose does not fit all patients - like many things biological?

Yes, thanks.

 

[Miloje]

Yes.

 

[BigDon]

So in India it's emerging that people who've been treated with steroids, especially diabetics, are developing a horrible fungal disease called mucormycosis. https://en.wikipedia.org/wiki/Mucormycosis

Unlike even the worst strains of Covid, this has a death rate of 50% with treatment! Utterly hair raising if you're familiar with how virulence math is compiled!