The use of inhaled corticosteroids in early-stage COVID-19

A small open-label trial suggested possible benefit in patients not admitted to hospital.4 Although there is a plausible mechanism for why inhaled corticosteroids could be beneficial, there are two reasons to be cautious: in the RECOVERY trial, although oral steroids offered benefit in seriously ill patients, they offered no benefit and possibly harm in those with less serious illness.3 And for those with COPD and asthma who do get infected, population studies suggest that use of inhaled corticosteroids is associated with worse outcomes.5,6 These inconsistent results leave primary care practitioners, heavily involved in care of high-risk patients with early-stage COVID-19 in the community, with little certainty of the potential benefits and harms of inhaled corticosteroids. The hospital admission or death outcome did not achieve the prespecified superiority threshold in the primary analysis population (72 [9%] of 787 in the budesonide group vs 116 (11%) of 1069 in the usual care group; model estimate 6·8% [95% BCI 4·1–10·2] vs 8·8% [5·5–12·7], odds ratio 0·75 [95% BCI 0·55–1·03]). Because vaccination was uncommon in trial participants, an important question is whether and what effect would be seen in the fully vaccinated population who have a different illness severity and trajectory.