COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting?

Russell, Beth; Moss, Charlotte; Rigg, Anne; Van Hemelrijck, Mieke

Most other included studies investigated the use of corticosteroids rather than NSAIDs during the treatment of coronaviruses [4, 5, 7-10, 12, 13] . Overall, we identified generally positive outcomes for the use of corticosteroids, particularly with reference to the SARS-CoV outbreak where they were widely used due to their known ability to modulate the inflammatory response. Various studies in humans noted that corticosteroids appeared effective in reducing immunopathological damage, but concerns centred around the promotion of viral rebound and association with adverse events (including acute respiratory distress syndrome). For example, a randomised controlled trial which measured viral load at regular intervals in non-intubated SARS-CoV cases found higher concentrations of viral RNA in week 2/3 of infection in those treated with corticosteroids compared to placebo [9] . Equally, a laboratory study which treated porcine respiratory coronavirus infected pigs with dexamethasone suggested that one or two doses of the corticosteroid in the acute phase of infection may effectively alleviate early pro-inflammatory response, but prolonged administration may play a role in enhancing viral replication [10] . Conversely, however, a separate Chinese study, which separated SARS-CoV patients into four treatment groups, identified early high dose steroids in combination with a quinolone produced the most favourable patient outcomes [5] . A similar mouse model study identified the N-protein of SARS-CoV as responsible for inducing pulmonary inflammatory reaction and acute lung injury which were related to the increase and imbalance of proinflammatory and anti-inflammatory cytokines [12] . Glucocorticoids, in the form of dexamethasone, effectively alleviated the pulmonary inflammatory reaction in these mice.