Corticosteroids (dexamethasone, prednisolone and hydrocortisone) for patients confirmed SARS-CoV-2 infection (Guidelines)

Warning

NHS Highland Guidance on use of corticosteroids (dexamethasone, prednisolone and hydrocortisone) for adults with confirmed SARS-CoV-2 infection.

Corticosteroids, and in particular dexamethasone, prednisolone and hydrocortisone, have been demonstrated to have a place in the management of patients with COVID-19. Following recent publication of the REMAP-CAP trial for hydrocortisone and a meta-analysis of corticosteroids, the World Health Organization (WHO) has issued interim guidance recommending the use of systemic corticosteroids in severe and critical COVID-19 disease.

The approach to utilisation of corticosteroids in COVID-19 is informed by the extensive experience of the use of this class of medicines for other indications and the information from the REACT meta-analysis where a clinical benefit was demonstrated. The REACT study includes results from seven randomised controlled trials (RCTs), including the RECOVERY and REMAP-CAP trials.  The majority of evidence in the published meta-analysis emanates from the assessment of dexamethasone in the RECOVERY trial.  Currently, there are no data directly comparing dexamethasone with hydrocortisone.

This guidance document has been updated with information from NICE COVID-19 rapid guideline: Managing COVID-19

Note: For information on use and doses in children, pregnant or breast-feeding women, please see:
the full NICE guidance, Royal College of Obstetrics and Gynaecology guidance and risk criteria set out in Royal College of Paediatric and Child Health Guidance for assessing children admitted to hospital with COVID-19

Eligibility critera

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

Community administration

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. 

Dosing schedule

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.  

Available formulations

Dose

Tablets 2mg

6mg = 3 tablets

Oral solution 2mg/5mL

6mg = 15mL

Intravenous injection 3.3mg in 1ml ampoules

6.6mg = 2mL (dose rounded up for ease of measurement)

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 with other COVID-19 treatments

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

Safety reporting

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/

Clinical outcome reporting

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).

Editorial Information

Last reviewed: 29/09/2023

Next review date: 30/09/2026

Author(s): Antimicrobial Management Team .

Version: 3

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Alison MacDonald, Antimicrobial Pharmacist, Alex Cochrane, Infection Diseases Consultant .

Document Id: COVID073