Intranasal corticosteroids have no adverse impact on COVID-19 mortality
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Key takeaways:
- Use of INCS was not linked to COVID-19-related mortality in the general population nor among patients with COPD or asthma.
- INCS use was associated with lower risk for all-cause mortality.
Exposure to intranasal corticosteroids did not have any adverse impact on COVID-19 mortality among a general population or among patients with asthma or COPD, according to a study published in Annals of Allergy, Asthma & Immunology.
However, trends toward lower risk for COVID-19 mortality with intranasal corticosteroid (INCS) use were not significant, Virginia Hernandez Santiago, MD, PhD, MSc, MRCGP, honorary senior clinical lecturer of the School of Medicine, University of St. Andrews, and colleagues wrote.
The study comprised 812,847 people who lived in Fife or Tayside, Scotland, between March 1, 2020, and May 31, 2021. The 50,326 (6.2%) in this cohort who used an INCS included 5,376 with COPD, 10,212 with asthma and 34,738 with no recorded chronic respiratory disease. Also, 10,252 (20.4%) used inhaled corticosteroids (ICS) with their INCS.
Overall, 3,530 (0.43%) individuals died during the study period, including 263 (0.03%) who died of COVID-19.
There were no significant associations between INCS use alone and mortality related to COVID-19 in the general population, nor in the asthma or COPD cohorts, in univariable and multivariable analyses, the researchers found.
Univariable analysis found a hazard ratio of 1.6 (95% CI, 1.04-2.5) for increased COVID-19 mortality with exposure to both ICS and INCS in the general population, but this association lost significance in the multivariable analysis. Results were similar in a sensitivity analysis of the effect on the general population when patients who had chronic respiratory disease were excluded.
Also, there were significant associations between INCS use alone or with ICS and reduced all-cause mortality among the general cohort and the COPD and asthma groups, and the sizes of their effects were similar, the researchers continued.
Specifically, results of multivariable analysis showed that, in the general population, there was a 40% decrease in all-cause mortality with INCS use (HR = 0.6; 95% CI, 0.5-0.65). Use of INCS and ICS together also had a protective effect (HR = 0.53; 95% CI, 0.5-0.6), the researchers found.
Excluding patients with COPD and asthma from the general population in a sensitivity analysis conferred similar results with a hazard ratio of 0.2 (95% CI, 0.04-0.7).
Researchers then focused on the COPD population (n = 42,994) — 2,874 (6.68%) of whom died of any cause and 217 (0.5%) of whom died of COVID-19 — and the asthma population (n = 72,237), 656 (0.91%) of whom died of any cause and 46 (0.06%) of whom died of COVID-19.
The COPD group experienced a 30% decrease in all-cause mortality with INCS use (HR = 0.7; 95% CI, 0.6-0.8) and a 50% reduction all-cause mortality with INCS and ICS use (HR = 0.5; 95% CI, 0.4-0.6).
The asthma group experienced a 50% decrease in all-cause mortality with INCS use (HR = 0.5; 95% CI, 0.3-0.7) compared with controls that did not use INCS. With INCS and ICS use, patients with asthma had a hazard ratio of 0.4 (95% CI, 0.3-0.5) for all-cause mortality.
Overall, the researchers found no association between INCS and any significant impact on mortality related to COVID-19. The effect was similarly nonsignificant, the researchers added, for INCS and ICS use.
Based on these findings, the researchers said there was an association between INCS use and lower risk for all-cause mortality even after they adjusted for baseline characteristics, but although the effect of INCS use on COVID-19 mortality trended in the same direction, there was no significant association.
Despite this lack of an adverse effect of INCS use on COVID-19 mortality, the researchers continued, associations between their use and inflammatory activation, viral load, ACE2 gene expression and outcomes including different types of intranasal steroids and doses are warranted.
Perspective
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These findings are not too surprising nor significant, in my opinion. I would not expect INCS to have a great effect on COVID-19 outcomes either way.
The fact that the authors found a possible protective association is nice, but I do not think that is conclusive enough to make any strong inference about the role that INCS could play in patients who get COVID-19.
Anecdotally, I have not noticed any differences in outcomes among my patients who are on INCS and those who are not when they do get COVID-19.
The take-home point for me, as a clinician, is that clinicians should not have any concerns about prescribing or having patients on INCS and having worse outcomes if they get COVID-19. In fact, it may have a protective effect, at least among those with asthma or COPD.
It would be tough to take this research much further. Prospectively enrolling cohorts of patients who use INCS vs. those who do not would be reasonable. But I do not think it is necessary, as I do not believe the juice would be worth the squeeze to carry out a large, prospective study like that.
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Hernandez Santiago V, et al. Ann Allergy Asthma Immunol. 2023;doi:10.1016/j.anai.2023.06.026.
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