by Dr. David Borenstein M.D.4/2020 EditortheSpineCommunity
The adrenal gland, situated just above the kidneys, produces a number of hormones that are essential for normal body function. Among these hormones is cortisol, a stress hormone. Addison’s disease is a fatal illness associated with the absence of cortisol. President John F. Kennedy had this illness and took cortisol replacement on a daily basis. The daily normal physiologic amount of cortisol produced by the adrenal gland is 20 mg of cortisol or 5mg of prednisone. Cushing’s disease is a group of illnesses associated with levels of cortisol above this normal amount. Increased levels of cortisol are also produced by the adrenal gland in the setting of stress. In the setting of increased amounts of cortisol, immune function response to foreign invaders is decreased. In the setting of rheumatoid arthritis, for example, prednisone 5mg can decrease the amount of joint swelling and redness associated with that illness. At higher doses of prednisone the immune system may not function to exclude foreign bacteria or viruses resulting in infections. The question about the use of corticosteroids in the setting of COVID-19 infection is particularly relevant in the setting of the pandemic.
The questions surrounding the use of corticosteroids ask whether these agents are useful in the treatment of severely ill individuals, and whether individuals who are on corticosteroids for an underlying illness should continue taking their medication. High dose corticosteroids have been utilized in the past for acute respiratory distress syndrome (ARDS). COVID-19 is considered a form of ARDS. Studies have suggested that individuals may benefit from precise corticosteroid therapy in the setting of COVID-19 lung involvement1 Other studies have shown no benefit and have recommended against the use of the medicine.2 The decision to use high dose steroids in the intensive care unit depends specifically on the circumstances affecting the individual patient.
The other concern is whether individuals who are taking corticosteroids for the treatment of an inflammatory condition should continue their therapy. A concern is the corticosteroids will increase the risk of “catching” the corona virus and should be discontinued. The NIH consensus guidelines for treatment of Covid-19 infection specifically state that corticosteroids should be continued for the treatment of an underlying disease Control of a hyperactive immune system is important in placing the monitoring function of the immune system in its most effective setting. An individual is not improved in regard to defending against COVID=19 if their underlying illness like ankylosing spondylitis or rheumatoid arthritis are active.
In the current setting of the pandemic, continuing medicines that control disease, physically distancing, and hand washing remain the specific means of limiting COVID-19 until an effective vaccine is developed.
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- Zhou W et al. Potential benefit of precise corticosteroids therapy for severe 2019-nCoV pneumonia. Sig Trans Target Ther 2020;5:18