Reply: Higher, but Not Too High, Dose Is Only One Determinant of Corticosteroid Treatment Success in Severe COVID-19

From the Authors:

We thank Dr. Salton and colleagues for their interest in our work (1) and their perspicacious commentary.

We agree it is important to consider multiple facets of corticosteroid regimens, including duration as well as dose, when administering the treatment. Further research should focus directly on this question.

Regarding patients who may benefit from corticosteroids, the landscape is changing rapidly, as patients are now most often vaccinated and receive additional immunosuppressive therapies, such as Jak-inhibitors and interleukin-6 receptor blockers. Our review included mostly trials in which these agents were unavailable and when most patients were unvaccinated.

To the authors’ point, it is imperative that we not include patients of all severities when treating with higher-dose regimens, particularly given the findings of the recent RECOVERY trial, which compared high- versus low-dose regimens in patients requiring simple oxygen only (2). This trial found significant harm in higher-dose regimens; however, it remains unclear exactly which effect moderators may play an important role in this regard.

Ultimately, optimal and appropriate dosing of corticosteroids is a priority for guidelines and clinicians in many fields, including coronavirus disease (COVID-19) as well as bacterial pneumonia (3). We look forward to future contributions to this area of research.