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Intranasal corticosteroids are associated with better outcomes in Coronavirus Disease 2019

Published: August 23, 2021

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused worldwide suffering and death of unprecedented magnitude. In both symptomatic and asymptomatic patients, higher viral loads have been detected by nasal swabs compared with throat swabs, which suggests that nasal epithelium is a major portal for viral entry and transmission. Angiotensin-converting enzyme-2 (ACE-2), a protein, has the highest concentration in the nose and is responsible for allowing the COVID virus to enter the epithelial cells and thus cause COVID-19 infection. Several in vitro studies have shown that corticosteroids decrease the concentration of ACE-2. To date, the role of intranasal corticosteroids (INCS) in COVID-19 has not been determined. In their recent study published in The Journal of Allergy Clinical Immunology: In Practice, Dr Strauss et al. tested the hypothesis that INCS use prior to SARS-CoV-2 infection is associated with decreased risk for hospitalization, admission to the intensive care unit (ICU), and death due to severe COVID-19.

To test their hypothesis, Strauss et al. used the Cleveland Clinic COVID-19 Research Registry (CCCRR), which includes data on all patients tested at the Cleveland Clinic for COVID-19 since March 8, 2020. To ensure quality, data were entered in electronic health records (EHR) using uniform templates and verified by trained medical personnel using standardized protocols. Out of the 72,147 patients included in the final analysis, 12,608 (17.5%) required hospitalization, 2,935 (4.1%) were admitted to the ICU, and 1,880 (2.6%) died during hospitalization. Most importantly, a significant number of patients (n= 10,187, 14.1%) were on INCS therapy prior to SARS-CoV-2 infection. Using a propensity score matching method, the authors found that INCS users had 22% decreased risk of hospitalization, 23% decreased risk of ICU admission, and 24% decreased risk of in-hospital mortality. Knowing that inhaled corticosteroids, allergic rhinitis (nasal symptoms from allergies), and eosinophilia (a type of white blood cell) could all potentially affect those results, sensitivity analyses were performed to address the potential confounding introduced by these factors.

In their study, Strauss et al. determined that chronic INCS use is associated with improved COVID-19-related outcomes. It is noteworthy that INCS are inexpensive, available over the counter, and can be used once a day. Future randomized controlled trials (RCTs) on the use of INCS and their role in the management of COVID-19 are needed. If proven effective, the benefits associated with INCS would be significant in reducing the need for healthcare resources including medications, oxygen supplies, and healthcare workers. Nevertheless, we are unable to recommend the use of INCS to either prevent or mitigate the effects of COVID-19 until proven with randomized controlled trials.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI focusing on practical information for the practicing clinician.

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