Steroids in Covid - Double edged Sword (With Notes on Anticoagulation)

-- by Dr. Parveen Gupta on May 10th, 2021

When to start Steroids in Covid-19?

  • All patients with oxygen saturation below 94% should be started on Steroids irrespective of day of illness.
    To detect oxygen saturation use pulse oximeter properly (middle finger of dominant hand, wait for 20 seconds). Oxygen saturation normal at rest but dipping to less than 94% after 6 min-walk-test, could be an early indicator of worsening disease.
  • If the symptoms (fever and/or cough) persist beyond five days: one may use Inhalational Budesonide (given by Nabulization or inhalers) at a dose of 800 mcg twice daily or more for five to seven days. Avoid adding Levolin/ Asthalin/ Duolin in inhalation/nabulization because these agents may cause dryness of secretions tremors and loss of sleep.
  • Treating physician may also choose to start oral Steroids if patient complains of sudden increasing weakness associated with high levels of rising CRP in second week of illness. Not even being able to go to toilet could be a common symptom of weakness .
  • Though, the ideal time for steroid initiation is after seven days of symptoms(when virus has very low tendency to replicate), in some patients with rapidly worsening symptoms, steroid can be initiated early to counter the rather aggressive immune dysregulation.

Which steroid to be used in what doses?

    Dexamethasone Sodium phosphate 8mg is equal to dexamethasone 6mg *oral/iv/im per day One may need to double the dose in severe cases.
    Dexametasobe is tried and tested affordable and easily available
    Or Methyl prednisolone 32 mg per day oral or IV
    Or Prednisone/ Wysolone 40mg per day oral

Precautions while giving steroids?

  • Blood sugar levels should be monitored even in those with no previous history of diabetes. Stress of disease coupled with steroids can lead shooting up of blood sugar. Monitoring is mandatory in diabetic patients.
  • Watch for secondary Bactetial/Fungal infection. For this reason, one may choose to add antibiotic cover to treatment

How to manage steroid-induced high blood sugar levels?

    Insulin under care of a physician remains best choice, but if patient is on home isolation with random blood sugar levels in range of 150 to 200mg, one may choose to start with DPP4 inhibitors like Vildagliptin 50mg with/out Metformin 500mg twice a day. If still not controlled, Insulin may be required under monitoring by a doctor.

Steroids should be strictly avoided in

5 to 10 days. No need to taper steroids after a short course of 5 days.

Steroids should be strictly avoided in

  • Asymptomatic patients
  • Patients with mild symptoms for less than 7 days
  • CT score less than 8 with disease duration less than 5 to 7 days
  • Viremia phase (high fever with normal CRP and CT)

Should one use anti-coagulants (blood thinners) with steroids?

    Yes, start anti-coagulants e.g.LMWH 40-60mg once a day in patients with Spo2 less than 94%. These are given in injection form.
    Newer anti-coagulants like Rivorexaban15 mg OD (Tab Rivoban/Xarelto etc) or Apixaban 2.5 mg BD (Tab Equilus) may if injection therapy can't be given during home bound treatment.
    In any case, patents should be switched over to oral Rivorexaban or Apixaban after 14 days of LMWH in case long term anticoagulation is planned

** Note :Rivorexaban or Apixaban are not to be used in preganant and lactating women.

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