Use of inhaled corticosteroids is not associated with improved COVID-related mortality in patients with chronic respiratory conditions

1. Patients with chronic obstructive pulmonary disease who were prescribed inhaled corticosteroids had an increased risk of COVID-19-related deaths compared to those on long-acting beta-agonist and long-acting muscarinic antagonist dual therapy.

2. Among asthma patients, a high-dose, but not low- or medium-dose, of inhaled corticosteroids was associated with an increased risk of COVID-related mortality compared SABAs only. 

Evidence Rating Level: 2 (Good)

Study Rundown: Early reports have described a relatively lower prevalence of COVID-19  than would be expected among patients with chronic respiratory conditions. These early findings have lead to speculations that the use of inhaled corticosteroids (ICS) – a commonly prescribed medication for respiratory disease – may have a protective function against SARS-CoV-2 infection. This observational cohort study sought to evaluate an association between ICS use and COVID-19-related death among patients with chronic obstructive pulmonary disease (COPD) and asthma. Patients on long-acting β agonist plus long-acting muscarinic antagonist (LABA-LAMA) dual therapy experienced fewer complications than those who were prescribed an ICS combination. Similarly, fewer asthma exacerbations were reported among individuals in the short-acting β agonist (SABA)-only group compared to those taking high-dose ICS. These results suggest that regular ICS use among patients with chronic respiratory disease is not associated with beneficial effects for COVID-19-related mortality. This study was limited by the presence of several confounding variables and misclassification, with some patients being incorrectly labelled as using a certain medication. Nonetheless, this study provides important insight into the role of inhaled corticosteroids in COVID-19-related clinical outcomes among a large group of patients in the UK.

Click to read the study in The Lancet Respiratory Medicine

Relevant Reading: Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19

In-depth [prospective cohort]: This observational cohort study followed 148 557 COPD patients and 818 490 asthma patients from March 1, 2020 to May 6, 2020 in England, UK. In the COPD population, 29.2% (n=43 308) of individuals were given a LABA-LAMA prescription and 70.8% (n=105 249) were given an ICS-LABA or ICS-LABA-LAMA prescription four months prior to enrolment. In the asthma population, 13.2% (n=108 441) of patients were given SABA-only, 12.3% (n=101 077) were given high-dose ICS, and the remaining 74.4% (n=608 972) received low-dose or medium-dose ICS. In both cohorts, the median follow-up time was 66 days (IQR 66-66).

For patients with COPD, median age was 71  years (IQR 63-77) for those in the LABA-LAMA combination group and 72 years (IQR 64-78) for those in the ICS combination group. For patients diagnosed with asthma, the median age was 48 years (IQR 35-60) in the SABA-only group, 53 years (40-66) in the low- or medium-dose ICS group, and 55 years (44-67) in the high-dose ICS group. Altogether, 429 COVID-19-related deaths occurred in the COPD cohort, with individuals on ICS combination having an increased risk of COVID-19-related fatality (adjusted Hazard Ratio [HR] 1.39, 95% CI 1.10-1.76). In the asthma population, 529 COVID-19-related deaths occurred. Here, individuals that were prescribed high-dose ICS had an increased risk of COVID-19-related complications (adjusted HR 1.55, 95% CI 1.10-2.18 for high-dose ICS) compared to individuals in the SABA-only group. A similar pattern was noted for the risk of non-COVID-19-related death. In the COPD cohort, the risk was higher among individuals prescribed ICS compared with those prescribed LABA-LAMA (HR 1.23, 95% CI 1.08-1.40). In conclusion, the authors found no evidence of a protective effect of ICS on COVID-19-related mortality among patients with COPD and asthma.

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