Clinical question
What is the effect of inhaled corticosteroids on length of illness, emergency department visits, and hospital admissions in outpatients with COVID-19?
Bottom line
Based on 2 open-label trials, higher-risk outpatients (≥1 comorbidity) with suspected or confirmed COVID-19 may benefit from 800 µg of inhaled budesonide twice a day for 14 days. Compared with usual care, budesonide shortened the time to recovery (12 vs 15 days), increased the proportion of patients recovering by day 14 (32% vs 22%), and reduced the need for health services (53% vs 59%).
Evidence
Results are statistically significant unless otherwise noted.
An RCT1 randomized 1856 symptomatic patients with COVID-19 aged 65 or older, or 50 or older with comorbidities, to 800 µg of inhaled budesonide twice a day for 14 days or usual care.
- Mean age was 64, about 80% had comorbidities (most common were hypertension and diabetes), and symptom onset was 6 days prior.
— First recovery day was at about 12 days with budesonide versus about 15 days with usual care.
— Rates of hospital admission or death were 6.8% with budesonide versus 8.8% with usual care. Results were not statistically different, but analysis suggests a 96% probability that the benefit was real.
- Other outcomes improved with budesonide:
— The proportion who recovered by 14 days was 32% versus 22% with usual care (number needed to treat [NNT]=10); contact with health services was 53% versus 59% with usual care (NNT=18).
Another RCT2 of 800 µg of inhaled budesonide twice a day (for duration of symptoms; median 7 days) or usual care followed 146 (generally younger or lower-risk) adults with COVID-19 symptoms (94% confirmed):
- The mean age was 45, there was a median 1 comorbidity per patient, and symptom onset was 3 days prior:
— Urgent care or higher-acuity visits were needed by 3% versus 15% with usual care (NNT=9).
— The proportion of patients with symptoms present at 14 days was 10% versus 30% with usual care (NNT=5).
Context
Systemic corticosteroids reduce mortality in hospitalized patients with COVID-19. Mechanically ventilated patients benefit the most; hospitalized patients not requiring oxygen experience no benefit or harm.3
Management guidelines for COVID-19 outpatients vary regarding inhaled budesonide, from not mentioning it,4 to not providing recommendations for or against it,5 to including it as a potential option.6
Cost is about $110 per inhaler.7
Implementation
Outpatients with COVID-19 have a growing number of treatments available to them. Antiviral agents (nirmatrelvir-ritonavir) and monoclonal antibodies (eg, sotrovimab) appear to reduce the risk of death or hospitalization,8,9 but patient eligibility and access vary by jurisdiction. Family physicians can provide inhaled budesonide at the point of care to those not eligible for antiviral agents or monoclonal antibodies.10 Fluvoxamine is also available, but its benefits are less certain than those of other treatments.11
Notes
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.
Footnotes
Competing interests
None declared
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