Abstract and Introduction
Background: The successful management of patients infected with coronavirus disease 2019 (COVID-19) with inhaled ciclesonide has been reported, however few studies have investigated its application among hospitalized patients.
Methods: This retrospective cohort study enrolled all adult patients admitted to our hospital with confirmed COVID-19 infection from May to June 2021. Critical patients who received mechanical ventilation within 24 h after admission and those who started ciclesonide more than 14 days after symptom onset were excluded. The in-hospital mortality rate was compared between those who did and did not receive inhaled ciclesonide.
Results: A total of 269 patients were enrolled, of whom 184 received inhaled ciclesonide and 85 did not. The use of ciclesonide was associated with lower in-hospital mortality (7.6% vs. 23.5%, p = 0.0003) and a trend of shorter hospital stay (12.0 (10.0–18.0) days vs. 13.0 (10.0–25.3) days, p = 0.0577). In subgroup analysis, the use of inhaled ciclesonide significantly reduced mortality in the patients with severe COVID-19 infection (6.8% vs. 50.0%, p < 0.0001) and in those with a high risk of mortality (16.4% vs. 43.2%, p = 0.0037). The use of inhaled ciclesonide also reduced the likelihood of receiving mechanical ventilation in the patients with severe COVID-19 infection. After multivariate analysis, inhaled ciclesonide remained positively correlated with a lower risk of in-hospital mortality (odds ratio: 0.2724, 95% confidence interval: 0.087–0.8763, p = 0.0291).
Conclusions: The use of inhaled ciclesonide in hospitalized patients with COVID-19 infection can reduce in-hospital mortality. Further randomized studies in patients with moderate to severe COVID-19 infection are urgently needed.
Coronavirus disease 2019 (COVID-19) has infected 404 million people and caused 5 million deaths worldwide. Several treatment options have been introduced, including systemic corticosteroids,[2–4] remdesivir, tocilizumab,[3,6] enoxaparin, and traditional Chinese medicine formula NRICM101. However, the effectiveness of these treatments is still under debate.
In the early months of the pandemic, Beurnier et al. reported a lower prevalence of asthma patients hospitalized with COVID-19 compared to the general population. There are several possible explanations for this finding. First, patients with asthma have been reported to have lower expressions of angiotensin-converting enzyme 2 (ACE2), the putative viral entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Second, chronic inflammation in asthmatic lungs caused by repeated epithelial insults may lead to a degree of immune tolerance, thereby restricting the development of the excessive inflammatory response in COVID-19.[11–13] Third, it may be related to a possible protective effect of inhaled corticosteroids (ICS).[9,14–16]
Anti-inflammatory medications, and especially corticosteroids,[3,4] have become popular in managing patients with severe COVID-19 infection since the RECOVERY trial. However, excess anti-inflammation may be detrimental for patients with milder disease. Compared with systemic corticosteroids, ICS have milder systemic effects, and have been shown to be effective in shortening the time to recovery among patients with mild COVID-19 infection.[19,20] Moreover, some studies have reported that corticosteroids may have anti-viral effects,[21–24] and reduce the expressions of ACE-2 and TMPRSS2. The successful management of patients with COVID-19 infection with inhaled ciclesonide has been reported,[25–27] however results from larger patient groups have been controversial or even suggested that ICS may be harmful.[28,29] Although growing evidence supports the potential role of ICS in the treatment of patients with mild COVID-19 infection and those who do not require hospitalization,[19,20,30–35] the use of ICS in hospitalized patients remains controversial. In 2020, we once successfully treated a patient with severe COVID-19 infection using inhaled ciclesonide. Considering the limited therapeutic options during the pandemic, our institution then included it as a possible treatment for COVID-19 infection. In this study, we retrospectively analyzed hospitalized COVID-19 patients during the first wave of the pandemic (2021) in Taiwan and compared the effect of inhaled ciclesonide between those who did and did not receive treatment.
BMC Pulm Med. 2022;22(368) © 2022 BioMed Central, Ltd.