COVID-19: Corticosteroids (Guidelines)

Note: guidance applies to all patients whether in hospital or other setting

Criteria for using systemic corticosteroid (intravenous or oral)

• Requirement for supplemental oxygen to meet prescribed oxygen saturation level (usually 94% but may be lower)
• Have hypoxia requiring oxygen but are unable to have or tolerate it.

Exclusion criteria for using systemic corticosteroid 

• Absence of any signs of severe or critical COVID-19
  Note: corticosteroid therapy should NOT be used in these patients

Corticosteroids can be prescribed in the community if the above criteria are met. 

As this is a sign of a deteriorating patient, please contact an acute hospital consultant. 

Dexamethasone

Adults 6 mg (oral or intravenous) once daily for 10 days. If there is a clear indication to stop early, including discharge from hospital, the 10 day course need not be completed.  

IV administration should only be used where tablets or oral solution are not appropriate or not available. 
Once the oral route is available, re-prescribe the drug with the oral dose (i.e. cannot prescribe the same dose as oral/IV ). 
When prescribing dexamethasone, consult the manufacturer’s information. 

Alternative options (if dexamethasone unsuitable or unavailable)

Prednisolone:
40mg orally once daily for 10 days (preferred in pregnancy – see link to RCOG guidance below)

Hydrocortisone:
Adults: 50mg given intravenously every 8 hours for 10 days.  A longer duration (up to 28 days) can be considered in patients with septic shock (as per REMAP-CAP trial).

Other factors

• Consider the risk of bleeding if on concurrent anticoagulation/ antiplatelet/ other pro-haemorrhagic therapy (particularly in the elderly) and need for gastric ulcer protection with proton pump inhibitors according to local policy.
• Monitor blood glucose levels.

Dosage in pregnancy

Follow Royal College of Obstetrics and Gynaecology guidance

Dosage for children with a greater than 44-week corrected gestational age

• Dexamethasone: 150 micrograms/kg (as a base) orally, nasogastrically or intravenously once a day for 10 days (max 6 mg)
• Prednisolone: 1 mg/kg orally, nasogastrically or intravenously once a day for 10 days (max 40 mg; doses can be rounded as per routine clinical practice) For patients able to swallow and in whom there are no significant concerns about enteral absorption, prescribe tablets. Only use intravenous administration when tablets or oral solutions are inappropriate or unavailable.

Dosage for preterm babies with a corrected gestational age of less than 44 weeks

Seek specialist advice.

Co-administration of dexamethasone, prednisolone or hydrocortisone with tocilizumab or remdesivir has not been studied but based on metabolism and clearance, a clinically significant interaction is unlikely (University of Liverpool COVID-19 Drug Interactions).

See separate TAM guidance for tocilizumab

Any suspected adverse drug reactions (ADRs) for patients receiving dexamethasone for this indication can be reported directly to the MHRA via the new dedicated COVID-19 Yellow Card reporting site at: https://coronavirus-yellowcard.mhra.gov.uk/

The Deputy Chief Medical Officer recommends that data on all patients with COVID-19 should be captured through the ISARIC 4C Clinical Characterisation Protocol (CCP) case report forms (CRFs), as coordinated by the COVID-19 Clinical Information Network (CO-CIN).