We are at the threshold of the third wave of COVID-19 with the highly transmissible Omicron variant infiltrating every country around the globe. With the cases rising at an exponential rate, it is helpful to be prepared rather than be overwhelmed. One of the most important drugs in our armamentarium that has proven beneficial is the corticosteroid but it has to be cautiously and logically used, and here are some FAQs answered by our expert, Prof. Dr. Nandini Chatterjee to help you out.

Question 1. When should you use steroids in COVID 19?

Indications:

1. Moderate and severe COVID-19 with rising oxygen demand and inflammatory markers (in oral or IV route).
2. Inhalational steroids are to be used in patients with mild disease with a new-onset of cough or fever.

Question 2. What is the dosage and duration of therapy?

The dosage and duration of therapy depend on the severity of the disease:

• Moderate disease: Dexamethasone- 0.1 to 0.2 mg/kg/day oral/IV for 5-10 days or Methylprednisolone 0.5 to 1 mg/kg/day orally or 40 mg IV for 5-10 days.
• Severe disease: Dexamethasone- 0.2 to 0.4 mg/kg/day for 5 to 10 days or Methylprednisolone- 1 to 2 mg/kg/day for 5 to 10 days.

Question 3. What is the role of inhaled steroids in COVID-19?

Inhaled corticosteroid (ICS) may be used in mild cases with new-onset cough or fever- inhaled Budesonide via metered-dose inhaler and spacer at a dose of 800 mcg twice daily.

Studies have suggested that ICS decreases ACE2 expression and thus decreases viral entry in airway epithelial cells. It has also demonstrated immunomodulatory effects. It has also been demonstrated to reduce severity and mortality risk not only in asthma and COPD patients but also in those without these comorbidities.

Question 4. What caution is to be exercised during steroid therapy?

1. A larger dosage than the recommendation and longer duration >3 weeks is to be avoided.
2. It is important to monitor BP and blood glucose levels.
3. Steroid-induced hyperglycemia (SIBG) may occur in both non-diabetics or previously known diabetics.
4. Look for evidence of secondary infections, both bacterial and fungal i.e, mucormycosis.
5. Corticosteroid decreases the plasma concentration of phenytoin, rifampicin and phenobarbital as it is an enzyme inducer. Hence, doses of these drugs may need to be increased.
6. There is also a risk of reactivation of latent infections like hepatitis B, tuberculosis, herpes virus and strongyloidiasis.

Question 5. How should you manage steroid-induced hyperglycaemia in COVID-19?

1. It is defined as elevated blood glucose in patients on steroids with or without pre-existing diabetes. FBG >=126 mg/dl, PPBG or random blood glucose >=200 mg/dl, HBA1c >6.5% . Glucose levels start to rise 1-2 days after initiation of steroid therapy in COVID patients.
2. Screening with fasting, postprandial and HBA1c levels is mandatory.
3. Monitoring is to be done with preprandial and postprandial levels. Fasting values may be normal in people with steroid-induced hyperglycaemia (SIHG), post-lunch values reflect glucose excursions best.
4. HbA1c helps in differentiating non-diabetic and pre-existing diabetic patients with hyperglycaemia. If the patient is on steroids, monitoring should be done at least 4 times a day (ideally should be done 6 times).
5. If premeal is <140 mg/dl and post-meal <180 mg/dl, the patient should have a healthy diet and monitoring.
6. If premeal is >140 mg/dl or post-meal level is 180-250 mg/dl, the patient should start oral therapy if there is mild COVID infection and no contraindication.
7. The target BG should be in between 100-140 mg/dl premeal,140-180 mg/dl post-meal.
8. Oral anti-diabetics like metformin, DPP4 Inhibitors is preferred for mild hyperglycaemia.
9. Sulphonylureas alone or in combination have shown a risk of hypoglycemia in COVID-19 patients and may be avoided. Also, SGLT2 inhibitors are not preferred due to the risk of dehydration and euglycemic DKA.

Insulin

1. If the premeal CBG is >=180 mg/ml and post-meal CBG exceeds 250 mg/dl insulin is to be initiated, preferably a basal-bolus regimen.
2. Also in cases of moderate to severe COVID with hyperglycaemia insulin is to be given.
3. The total daily dose is 0.4 U/kg/day- three bolus doses before meals with basal insulin at night. For SIHG, higher doses may be required. Lower doses are to be used in CKD, CLD or elderly patients. Postprandial excursion of blood glucose is to be <40-50 mg /day.
4. IV insulin is to be instituted if hyperglycaemia is not controlled or there is a critical illness, sepsis with or without shock.
5. 0.05-0.1 mg/kg/day to be started with a target of 141-180, can be switched to basal-bolus if there is no haemodynamic instability.

To conclude, the use of steroid therapy has proven benefits in COVID-19 infection. But the drug has some side effects, so its usage should be cautious and optimal with frequent monitoring.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr Nandini Chatterjee is a professor of medicine at IPGMER /SSKM Hospital from Kolkata.