The Association of Inhaled Corticosteroid Before Admission and Survival of Patients with COVID-19

Inhaled corticosteroids (ICSs) are widely used in patients with asthma and chronic obstructive pulmonary disease (COPD). Herein, we are highly concerned about whether the use of ICSs affects the prognosis of COVID-19.

We retrospectively analyzed >6095 hospitalized patients with laboratory-confirmed COVID-19 at the Mount Sinai Health System in New York between March 1 and May 2, 2020. Patients were stratified into those with or without ICSs before admission and were assessed for in-hospital mortality as a primary outcome. Patients were matched by propensity score using 1:1 matching scheme without replacement. We performed this analysis with and without multiple imputation for missing data and then performed an inverse probability weighted analysis. All statistical calculations and analyses were performed in R, with p-values <0.05 considered statistically significant.

A total of 333 patients (5.5%) used ICSs before admission. The patients with ICSs were older and had more comorbidities than the patients without ICSs (Table 1). However, in-hospital mortality, intensive care unit admission, and endotracheal intubation rate were not significantly different, although the D-dimer levels were significantly lower in patients with ICSs compared with those without (1.48 [0.88, 2.76] vs. 1.66 [0.88, 3.51] μg/mL, p = 0.043). After matching by propensity score (N = 204 in each group), in-hospital mortality and intensive care unit admission rate were not different, whereas endotracheal intubation rate was significantly decreased in the patients with ICSs (Table 1). Multiple imputation for missing data and inverse probability weighted analysis revealed no significant difference in in-hospital mortality between the groups (odds ratio [95% confidence interval]: 0.90 [0.61–1.34], p = 0.63; odds ratio [95% confidence interval]: 0.83 [0.54–1.29], p = 0.42).

To identify the population ICS improves the prognosis of COVID-19, we performed a subgroup analysis among patients with asthma and COPD (N = 378). There was no significant difference in in-hospital mortality between patients with ICSs and those without even after propensity score matched analysis or inverse probability weighted analysis (odds ratio [95% confidential interval]: 0.86 [0.47–1.60], p = 0.64) (Table 1).

The impact of ICSs on the susceptibility and severity of COVID-19 has not been well established. The pooled epidemiological studies have shown that patients with asthma or COPD are at lower hospitalization risk, which could be related to the protective effect of ICSs.^(1,2) However, some studies showed no protective effects of ICSs on the prognosis of COVID-19.^(3,4) The very recent study suggested that the use of ICSs, within 2 weeks of admission, improved survival only for patients aged 50 years and older with asthma, but not for those with chronic pulmonary disease.⁽⁵⁾ Thus, the role of ICSs in COVID-19 is still controversial.

In this retrospective analysis, antecedent ICS use showed numerically better outcomes in the propensity score matching analysis and the subgroup analysis of patients with asthma and COPD even though the patients with antecedent ICS use had more comorbidities. Particularly, our propensity score matching analysis revealed that patients with antecedent ICSs use showed decreased endotracheal intubation rate. The potential benefit of antecedent ICS use on COVID-19 patients needs to be examined with larger sample size.

This study was approved by the institutional review boards (no. 2000495) and conducted in accordance with the principles of the Declaration of Helsinki. The waiver of patients' informed consent was also approved by the institutional review boards.