Patients on Steroids With COVID-19 Might Need Rescue Steroids

 

Endocrinologists have underlined the importance that physicians consider “a stress dose” of glucocorticoids in the event of severe COVID-19 infection in endocrine, and other, patients on long-term steroids.

 

People taking corticosteroids on a routine basis for a variety of underlying inflammatory conditions, such as asthma, allergies, and arthritis, are at elevated risk of being infected with, and adversely affected by, COVID-19.

 

This also applies to a rarer group of patients with adrenal insufficiency and uncontrolled Cushing syndrome, as well as secondary adrenal insufficiency occurring in hypopituitarism, who also rely on glucocorticoids for day-to-day living.

 

In the event of COVID-19, all of these individuals may be unable to mount a normal stress response, and “in the case of adrenal suppression…such patients may run into severe difficulties, particularly if on intensive care units,” warns Paul Stewart, MD, University of Leeds, UK, and editor-in-chief of the Journal of Clinical Endocrinology & Metabolism (JCEM).

 

As such, it is vitally important to recognize that “Injectable supplemental glucocorticoid therapy in this setting can reverse the risk of potentially fatal adrenal failure and should be considered in every case,” Stewart and colleagues emphasize in a newly published editorial in JCEM.

 

They note this advice must be considered alongside World Health Organization (WHO) guidance against prescribing therapeutic glucocorticoids to treat complications of COVID-19, based on prior experience in patients with acute respiratory distress syndrome, as well as those affected by severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).

 

The key difference here is not to use pharmacologic doses of glucocorticoids as treatment for COVID-19 (where they have no effect), but rather to prevent death from adrenal failure by using “stress” doses of replacement glucocorticoid, Stewart explained to Medscape Medical News.

 

“No patient with a history of prior exposure to chronic glucocorticoid therapy (> 3 months)…should die without consideration” for a stress dose of replacement glucocorticoid therapy.

“The intent here is to ensure that no patient with a history of prior exposure to chronic glucocorticoid therapy (> 3 months) by whatever route should die without consideration for parenteral glucocorticoid therapy,” the editorialists write.

 

He advises using physiological stress doses of hydrocortisone (50-100 mg intravenously tid).

 

Specific Advice for Adrenal Insufficiency: Follow Sick Day Rules

 

separate statement by the American Association of Clinical Endocrinologists (AACE) also emphasizes that it is particularly important for patients with adrenal insufficiency to follow advice from the Centers for Disease Control and Prevention (CDC) or similar guidance on preventing COVID-19 infection, including social distancing and frequent hand washing.

 

Such patients should continue to take medications as prescribed and ensure they have appropriate supplies of oral and injectable steroids, ideally for 90 days, AACE advises.

And if there is a shortage of hydrocortisone, the statement advises patients ask a pharmacist or physician about replacement hydrocortisone with different doses that might be available.

Stewart agrees that patients with adrenal insufficiency need to be hypervigilant, but says that “if they do become ill, for the most part they are well counseled to respond appropriately to intercurrent infections.”

Nevertheless, it is “invaluable to reiterate ‘sick day rules'” for suspected COVID-19 infection.

“Any patient who develops a dry continuous cough and fever should immediately double their daily oral glucocorticoid dose and continue on this regimen until the fever has subsided.”

If a patient still deteriorates on this regimen, develops diarrhea or vomiting, or is unable to take oral glucocorticoids for other reasons, they should contact their physicians or seek urgent medical care to receive parenteral treatment with a glucocorticoid.

J Clin Endocrinol Metab. Published online March 31, 2020. Position statement

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From https://www.medscape.com/viewarticle/928072?nlid=134869_3901&src=wnl_newsalrt_200404_MSCPEDIT&uac=295048SY&impID=2335560&faf=1&fbclid=IwAR1zZe6fqDS3tKuHUYoFpbvBMkQYJ4JN59RzC93xdzVcGGkJIz5bnmmE4LY

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