Glucocorticoid Use in COVID-19: Who Benefits and Why It Matters

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Glucocorticoid Use in COVID-19: Who Benefits and Why It Matters

For patients with severe COVID-19, one question has lingered since the pandemic began: when should glucocorticoids—powerful anti-inflammatory drugs like dexamethasone or methylprednisolone—be used? Yun’ai Feng and Haichao Li from the Department of Respiratory and Critical Care Medicine at Peking University First Hospital in Beijing explore this question in a 2022 discussion published in the Chinese Medical Journal, offering clarity on who stands to gain from these treatments and why precision matters.

The Evidence for Glucocorticoids in Severe COVID-19

The landmark RECOVERY trial (2021) set the stage: glucocorticoids improve outcomes for severe COVID-19 patients (e.g., those on oxygen or mechanical ventilation) but offer no benefit for mild disease. Follow-up trials like CoDEX (focused on COVID-19-associated ARDS) and DEXA-ARDS (dexamethasone for ARDS) reinforced this finding, leading to global guidelines recommending glucocorticoids for severe cases. Yet researchers have continued to ask: How do these drugs help?

The Lung Pathology Connection

Diffuse alveolar damage (DAD)—a severe lung injury marked by fluid buildup and cell death—is the most well-known COVID-19 complication. But it’s not the only one. Some patients develop organizing pneumonia (OP) (scarring in lung airways) or acute fibrinous and organizing pneumonia (AFOP) (a mix of inflammation and scarring). Here’s the critical insight: glucocorticoids have little effect on DAD, but they do work for secondary OP and subacute AFOP—conditions linked to better responses to anti-inflammatory therapy.

COVID-19-related acute respiratory distress syndrome (ARDS) also plays a role. The disease causes two types of ARDS:

  • Type 1 (atypical): Low lung elasticity, better compliance (stretchiness), and ventilation/perfusion imbalances.
  • Type 2 (classic): High elasticity (stiff lungs), reduced compliance, and oxygen flow issues (often from AFOP).

Some Type 2 patients with AFOP see significant benefits from glucocorticoids—a key reason why identifying which lung injury a patient has matters.

Who Should Get Glucocorticoids? Look to CT Scans

The authors emphasize that patient selection is everything to avoid unnecessary side effects (e.g., weakened immunity, high blood sugar) and maximize benefits. Computed tomography (CT) scans can spot the lung patterns that predict a good response:

  1. Bilateral, peripheral, lower-lung consolidation: A hallmark of OP.
  2. Bronchial consolidation + patchy ground-glass opacities: Found in the lower lobes’ subpleural area (also OP).
  3. Focal/diffuse lung abnormalities similar to OP: A sign of subacute AFOP.

A 2020 meta-analysis by the WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group supports this approach: systemic corticosteroids reduce 28-day all-cause mortality in critically ill COVID-19 patients compared to usual care or placebo.

Drug Choice Matters for Ventilated Patients

For COVID-19 patients on mechanical ventilation, the dose and type of glucocorticoid also matter. A 2021 study in J Intensive Care Med found that methylprednisolone (≥1 mg/kg/day for at least 3 days) lowers mortality more effectively than dexamethasone (≥6 mg/day for 7+ days)—a crucial detail for ICU teams.

Why This Discussion Matters

Glucocorticoids are not a “one-size-fits-all” solution for COVID-19. But for patients with OP or subacute AFOP—identified via CT scans—they can be life-saving. By targeting these patients, doctors improve treatment accuracy, boost survival, and reduce the risks of overusing these powerful drugs.

Original discussion: Feng Y, Li H. Further discussion on glucocorticoid treatment of COVID-19. Chinese Medical Journal. 2022;135(11):1386. doi:10.1097/CM9.0000000000001872

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