Systemic Corticosteroids, but Not Biologics, Worsen COVID-19 Outcomes in Patients With Asthma

The more often a patient used systemic corticosteroids, the higher their risk of moderate or severe COVID-19 and all-cause mortality, the study found.

Patients who take biologics or systemic corticosteroids (SCS) to control their asthma are not at a higher risk of SARS-CoV-2 infection, but those taking steroids have a greater likelihood of severe disease if they become infected, according to new research.

Corresponding author Yochai Adir, MD, MHA, and colleagues wrote in the Journal of Allergy and Clinical Immunology that while many respiratory viral infections can heighten the risk of asthmatic exacerbations, existing evidence so far has suggested the same is not true of SARS-CoV-2, the virus that causes COVID-19. Yet, the management of patients with asthma remains a challenge during the pandemic, they said, “because it is unclear whether patients with severe asthma could be at a higher risk of worst outcomes at least in part because of safety concerns associated with therapies such as biologics or systemic corticosteroids (SCSs).”

In order to gain a better picture of the risk, Adir, of Lady Davis Carmel Medical Center in Israel and colleagues used a database containing records for more than half of the Israeli population to identify patients with asthma who used biologics or SCS, and then compare their COVID-19 infection rates and outcomes to those of the general population.

They found more than 80,000 asthmatic adults who underwent PCR testing between March and December 2020. Of those, about 10% (8242 patients) tested positive.

Neither biologics nor SCS use was linked with a greater risk of infection, and the use of biologics did not appear to correlate with an increased risk of disease severity or all-cause mortality. However, patients who had used SCS within the previous 120 days faced a heightened risk of both moderate to severe COVID-19, as well as a higher risk of death. The risk went up the more a patient used steroids.

“Chronic SCS use was associated with significantly increased risk of all tested outcomes: adjusted HR 2.19 (95% CI, 1.63-2.94) for moderate to severe COVID- 19, HR 2.00 (1.18-3.40) for all-cause mortality, and HR 2.07 (95% CI, 1.55-2.76) for the composite of moderate to severe COVID-19 or all-cause mortality,” they found.

The data were based on 1358 patients with recent SCS use and 50 patients who were taking biologics.

Adir and colleagues said their new analysis adds to the existing literature surrounding the role of asthma medication in COVID-19 outcomes, but they said it is difficult to draw clear conclusions, since some studies have drawn conflicting results. They said their study offers reassuring evidence with regard to biologics, but suggests physicians should be cautious about SCS use.

“Indeed, SCS use decreases innate and acquired immunity and predisposes to infection,” they wrote. “Therefore, it is recommended to avoid chronic or repeated SCS use whenever possible, and to prescribe the lowest possible dose of SCS in the subgroup of severe asthmatic patients requiring long-term treatment with oral corticosteroids.”

Patients with severe uncontrolled asthma should be managed using steroid-sparing approaches, such as biologics, in eligible patients, they said.

“Our data suggest that these treatments may help in achieving asthma control and by inference prevent worst outcomes when patients are infected with SARS-CoV-2,” they said.

While it will take time and larger studies to fully understand the links and risks between asthma medication and COVID-19 risk, Adir and colleagues said patients with asthma warrant closer supervision during the pandemic, since even if their risk of infection is no higher than the average patient, the consequences of an infection could be much more severe.


Adir Y, Humbert M, Saliba W. COVID-19 risk and outcomes in adult asthmatic patients treated with biologics or systemic corticosteroids: Nationwide real-world evidence. J Allergy Clin Immunol. Published online June 15, 2021. doi:10.1016/j.jaci.2021.06.006

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