If you, like the skeptical cardiologist, suffer from asthma you may be wondering if you are at a higher risk of contracting Covid-19 or developing more severe respiratory complications from the disease once infected.
There are 25 million asthma sufferers in the United States, about 8% of the population and many of us are using as primary treatment a combination of inhaled beta-agonists (for immediate relief) and inhaled corticosteroids (ICS) (for long-term conditioning of the lung).
How are these treatments influencing our risks during the Covid-19 pandemic?
A commentary published online in Lancet Respiratory medicine suggested that there is a lower prevalence of asthma in patients with Covid-19. However, the sum of evidence from this commentary and elsewhere is insufficient to say asthma is protective.
When there is an absence of evidence, as we saw with hypertension as a risk factor and hydroxychloroquine as a treatment, the tendency of journalists is to obtain a quote from a physician who has treated patients with Covid-19 to buttress a particular argument. Quotes which say something like “we don’t know” or “there is not enough evidence right now” are highly unlikely to be published whereas anecdotal speculation is always intriguing (but often misleading.). The New York Times published this quote on the topic:
“We’re not seeing a lot of patients with asthma,” said Dr. Bushra Mina, a pulmonary and critical care physician at Lenox Hill Hospital in New York City, which has treated more than 800 Covid cases. The more common risk factors, he added, are “morbid obesity, diabetes and chronic heart disease.”
A major problem in sorting out asthma as an independent risk factor is that many papers are lumping all “chronic respiratory diseases” together which puts asthma in a bucket with chronic obstructive pulmonary disease (COPD) and interstitial lung disease like pulmonary fibrosis. There are striking differences in the demographics and prognosis of these diseases. For example, patients with COPD are older and much more likely to have smoked cigarettes, two factors clearly associated with Covid-19 risk.
In addition, asthma in older adults is highly associated with obesity, a well-recognized independent risk factor Covid-19 complications.
Among adults aged 60 and over, there was a significant trend of increasing asthma prevalence with weight status: 7.0% among normal weight adults; 9.1% among overweight adults; 11.6% among adults with obesity.
In addition, almost no data is available on asthma stratified by severity and treatment. The severe asthma patient who requires oral corticosteroids is markedly different from the mild asthmatic whose only treatment is intermittent inhaled beta-agonists.
These data, like the data on hypertension, should be taken with a grain of salt, but at a minimum, we can say there is no signal that asthma by itself increases the risk of Covid-19 infection.
Inhaled Corticosteroids and Covid-19
The authors* of the commentary in Lancet which implied asthma (and chronic respiratory disease) was protective against Covid-19 infection also concluded that
“the possibility that inhaled corticosteroids might prevent (at least partly) the development of symptomatic infection or severe presentation of COVID-19 cannot be ignored”
They cited some very preliminary data to support this contention:
in in-vitro models, inhaled corticosteroids alone or in combination with bronchodilators have been shown to suppress coronavirus replication and cytokine production. Low- quality evidence also exists from a case series in Japan, in which improvement was seen in three patients with COVID-19 requiring oxygen, but not ventilatory support,
Personally, I have always worried that my use of ICS put me at a higher risk of respiratory infections because corticosteroids are potent immunosuppressives, potentially lowering my immune response to bacterial, viral, or fungal infections. This 2019 meta-analysis in Infection found a 24% higher rate of upper respiratory tract infection in patients using ICS.
Due to these concerns, when the pandemic began I purposely cut back on my Advair usage. Fortunately, my asthma has been very mild since I started taking Dupixent for eczema 3 years ago. Since then, Dupixent has been approved for treatment of asthma. (By the way, although dupilumab is a targeted biologic therapy that inhibits signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13), two key proteins that may play a central role in type 2 inflammation that underlies atopic dermatitis and several other allergic diseases we have no idea if it increases or decreases Covid-19 risks or complications.)
Does ICS usage increase or lower our risk of Covid-19 outcomes?
This figure from a review of the topic shows where in the process ICS could influence Covid-19, either increasing or decreasing risk of 1) initial infection 2) progression to pneumonia or 3) progression to ARDS and death once pneumonia is established.
There are theoretical arguments to suggest the use of ICS could either improve or worsen all 3 stages.
The review of 59 publications on Covid-19 concluded:
Following examination of the full texts including translations of those in Chinese, no publications were identified as having data on prior ICS use in patients with SARS, MERS or COVID-19 infection. No data were available for either a qualitative or narrative answer to the review question.
The bottom line right now is that we don’t know if ICS use is an important risk factor in Covid-19 outcomes.
Should ICS Stay or Go?
The recommendations of the CDC, and all pulmonary/asthma societies at this point is to stick to your current asthma action plan. If that includes taking an ICS, keep on taking it at current levels.
In fact, the AAAAI and other major asthma or pulmonary organization emphasize that patients should remain on their current medications because experiencing an exacerbation event and the need for hospitalization, in those who become poorly controlled, could actually increase patient exposure and the risk of infection.
I’ve gone back to taking my ICS at pre-pandemic levels and I don’t consider that my asthma puts me at any higher risk during the pandemic.
Skeptically Yours,
-ACP
N.B. Common inhaled corticosteroids include:
- Beclomethasone (QvarTM)
- Budesonide (Pulmicort FlexhalerTM)
- Ciclesonide (AlvescoTM)
- Flunisolide (AerospanTM)
- Fluticasone (Flovent Diskus TM, Flovent HFATM, Arnuity ElliptaTM)
- Mometasone (AsmanexTM)
ICS are commonly combined with long-acting beta agonists. The “purple circle” Advair is one such combination.
N.B. The authors of the Lancet commentary seem to have heavy ties to companies that stand to profit from sales of ICS
DMGH has received personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Pfizer, and Sanofi, and non-financial support from Boehringer Ingelheim and Novartis, outside of the submitted work. RF has received grants from GlaxoSmithKline and Menarini, outside of the submitted work. AA has received grants from AstraZeneca, GlaxoSmithKline, and Menarini, and personal fees from AstraZeneca, Chiesi, GlaxoSmithKline, and Menarini, outside of the submitted work. OS and JRB declare no competing interests
Here are the references they cited suggested ICS might be beneficial against coronavirus.
- Yamaya M, Nishimura H, Deng X, et al. Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells. Respir Investig 2020; published online Feb 21. DOI:10.1016/j.resinv.2019.12.005.
- Matsuyama S, Kawase M, Nao N, et al. The inhaled corticosteroid ciclesonide blocks coronavirus RNA replication by targeting viral NSP15. bioRxiv 2020; published online March 12. DOI:10.1101/2020.03.11.987016 (preprint).
- Iwabuchi K, Yoshie K, Kurakami Y, Takahashi K, Kato Y. Morishima T. COVID-19. Three cases improved with inhaled ciclesonide in the early to middle stages of pneumonia. 2020. http://www.kansensho.or.jp/uploads/ files/topics/2019ncov/covid19_casereport_200310.pdf (accessed March 27, 2020; in Japanese).
11 thoughts on “Asthma, Inhaled Steroids and Covid-19”
I suspect that ICS are your ally against COVID. This study found decreased expression of SARS-CoV-2 entry targets ACE2 and TMPRSS2 in asthmatics in response to ICS, and suggest a study to see whether ICS decreases risk of infection and severe disease.
Peters, Michael C., et al. “COVID-19–related genes in sputum cells in asthma. Relationship to demographic features and corticosteroids.” American journal of respiratory and critical care medicine 202.1 (2020): 83-90. https://doi.org/10.1164/rccm.202003-0821OC, PubMed: 32348692
While ICS is not going to be as affective as dexamethasone to reduce vascular inflammation and the clotting that is responsible for most of the COVID fatalities (Fodor et. 2021), it could help locally early in infection.
Just saying…
Fodor, Adriana, et al. “Endothelial Dysfunction, Inflammation, and Oxidative Stress in COVID-19—Mechanisms and Therapeutic Targets.” Oxidative Medicine and Cellular Longevity 2021 (2021).
Watchinit,
It makes sense but I’d like to see the results of an RCT before prescribing inhaled steroids to those not already using them.
Dr P
My son with intermittent asthma caught Covid and strep. His high fever didn’t respond to ibuprofen and spiked to 104. Interestingly enough, our local children’s hospital was immediately preparing a Covid room for him and the second employee at check in told me overall they had tested 7k patients and only admitted 10. My boy became #11 yesterday. Normally, if we came in for asthma, we would be given albuterol mixed with pulmicort. As the Covid ED was in an old psych room, there was no built in the wall O2 or nebulizer hookup. I thought this strange since his pulse ox was 91 and that was the normal protocol. A respiratory therapist came in and gave him 8 puffs of albuterol through a spacer and that was discontinued unless the 16 year old asked for it himself. I had read about a Texas doctor giving pulmicort, a zpack and zinc as to address the inflammatory nature of Covid, the bacteria the pneumonia could grow and the inhibition of virus replication. My son was given strong antibiotics because his symptoms triggered a sepsis warning in the nurse’s computer. But there was nothing given for opening of airways. His pulse ox dipped into the 80s many times but they released him anyway because it went back to the low 90s. I’m not a doctor, but I do live in a house of of four asthmatics, including myself. My youngest has a peanut allergy. I’m loving what your article examines because I was met with dismissive attitudes when the hospital staff changed staff for the day. It gives me hope that doctors will consider treatments that might already be indicated for symptoms Covid is presenting. Also, your writing shed some light on what was listed on the reason for my son’s admission- morbid childhood obesity. His BMI reads as greater than 99th percentile, but he’s 6’2” and 260, and the last 60 lbs he’s gained according to his GP is straight muscle from football training. But that’s the rationale for insurance to justify the hospitalization.
I use a LABA when needed. Usually when I get sick. I’ve not had an asthma attack ever. Just can get some tightness. But after reading this blog I researched a bit and saw that a LABA alone can be problematic. Now not sure if I should use it at all.
If you haven’t already done so, I recommend trying N-acetyl cysteine 600 mg daily. This supplement is helpful for any lung problem and may help to prevent COVID-19. The inhaled form is called Mucomyst.
Guessing you’ve seen this, from MedPage:
https://www.medpagetoday.com/infectiousdisease/covid19/86323?xid=nl_mpt_SRPrimaryCare_2020-05-06&eun=g1011759d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=PCUpdate_050620&utm_term=NL_Spec_Primary_Care_Update_Active
I did towards the end of my researching the topic.
I found it featured the quotes of a single pulmonologist citing shaky sources which I had already vetted.
“As we look at data coming out of areas strongly affected by the pandemic, one very striking thing is the lack of high rates of patients with asthma having severe effects” of COVID-19, Rogers said.
For example, she pointed to data from Wuhan, China, indicating that 5% of people in China have asthma yet it was seen in fewer than 1% of patients hospitalized for COVID-19.
Rogers also cited mortality statistics from the New York State Department of Health, in which “asthma is not even in the top 10″ comorbidities, even though 8%-10% of New York’s population has asthma. Rogers noted chronic obstructive pulmonary disease (COPD) comes in after hypertension, diabetes, as well as other types of cardiovascular disease, dementia, and renal disease.”
After reviewing the Lancet commentary (Wuhan data) and the NY data I didn’t find anything worthy of citing to support the idea that asthma was protective.
Advair absolutely changed my life back in the early 2000s, but my insurer refused to cover it about five years ago. After a side trip to Symbicort, I am now using Dulera and have wondered myself about its true risk in the COVID-19 pandemic. Thank you for answering all my questions and the solid advice.
The ICS/LABA combos have been great for me also. I grew up with horrible asthma and the major treatments were oral steroids (horrible side effects) or Tedral which is a combination of theophylline, ephedrine, and phenobarbital. Why the phenobarbital? Because theophylline and ephedrine make you feel like you are on speed and you need something to calm you down! (see http://asthmahistory.blogspot.com/2017/02/1978-tedral-and-brondecon.html)
I came across my old doctors bag recently and found a bottle of Tedral in it. Chills went up and down my spine.
The insurers seemed to sour on Advair a few years ago and also made me switch but now I seem to get it without any issues.
Chicken soup: “try it, you might like it.” You might improve/clear your asthma (and eczema) by discontinuing dairy 100(100!!!) %. Also go gluten free. Generally, animal protein is more antigenically complex than vegetable protein: hence,move TOWARDS (90+% will do just fine) being organic unprocessed whole food vegan wi wild caught fish twice a week. “Try it (for 3 months), you might like your new freedom. HRS,MD, FACC
Do you have a reference for any of these bold statements?
Perhaps, at least to support that statement that “animal protein is more antigenically complex than vegetable protein”?