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Role of Budesonide in Corona Virus Disease: Systematic Review

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Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
4902
http://annalsofrscb.ro
Role of Budesonide in Corona Virus Disease: Systematic Review
Dr. BalaYaduVamsi Sankuratri1
, Dr. Rahul VC Tiwari2
, Dr. Aarushi Shekhar3
, Dr.
Abhimanyu Singh4
, Dr. AjithBabu Poovathingal5
, Dr. MyleshRavisankar
Dakshinamurthy6
, Dr. Heena Tiwari7
1
BDS, MPH, University of Texas at Arlington, Texas. byv.sankuratri@gmail.com;
2
OMFS, FOGS, PhD Scholar, Dept of OMFS, Narsinbhai Patel Dental College and Hospital,
Sankalchand Patel University, Visnagar, Gujarat,384315. drrahulvctiwari@gmail.com;
3
P.G Student , Department of Conservative and Endodontic Dentistry, BabuBanarasi Das
College of Dental Science, Lucknow. aarushishekhar367@gmail.com;
4
P.G student, Department of Pediatric and Preventive Dentistry, Saraswati Dental College,
Lucknow. abhimanyusingh.2405@gmail.com;
5
MBBS MD, Internal Medicine Registrar at Unity Hospital, Kanipayoor, Thrissur district,
Kerala. ajithbabu13@gmail.com;
6
4th year MBBS student at Yerevan State Medical University, Yerevan, Armenia.
myleshravisankar@gmail.com;
7
BDS, PGDHHM, MPH Student, ParulUniveristy, Limda, Waghodia, Vadodara, Gujrat,
India.drheenatiwari@gmail.com
Corresponding Author:
Dr. BalaYaduVamsiSankuratri, BDS, MPH, University of Texas at Arlington, Texas.
byv.sankuratri@gmail.com
ABSTRACT:
Background: The current COVID-19 pandemic caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) infection, raises important questions as to whether pre-morbid use
or continued administration of inhaled corticosteroids (ICS) affects the outcomes of acute
respiratory infections due to coronavirus.
Purpose of study:Inhaled budesonide is a low cost, safe (time censored), effective (number
needed to treat of eight) simple and widely available therapeutic option, which can be of great
help around the world, particularly in low-income and middle-income countries. Several
potential mechanisms might underlie these clinical observations.
Results: Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of
requiring urgent care, emergency department consultation and hospitalization.
Conclusion: The budesonide group reported greater wellbeing of the patients. Also scales down
the need for urgent medical care and reduces recovery time, if given early to Covid-19 patients
with mild symptoms.
Key Words: Budesonide, COVID, Corona Virus.
INTRODUCTION
The current COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection, raises important questions as to whether pre-morbid use or continued
administration of inhaled corticosteroids (ICS) affects the outcomes of acute respiratory
infections due to coronavirus[1]. In most individuals, infection with SARS-CoV-2 is either
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
4903
http://annalsofrscb.ro
asymptomatic or produces mild illness (COVID-19) that resolves spontaneously; yet, a small
proportion of patients with COVID-19 develop severe disease, require hospitalisation (often in a
critical-care setting) and die. COVID-19 has an initial period characterised by cough and fever,
followed after around 8 days in approximately 20% of patients by the development of dyspnoea
with pulmonary infiltrates in about 10% [2,3]. Approximately a quarter of patients admitted to
hospital developed acute respiratory distress syndrome (ARDS) after a median of 10.5 days after
symptom onset [3]. A dysregulated type I interferon response to SARS-CoV-2 with
overproduction of proinflammatory cytokines seems to be a key pathogenic mechanism
underlying progression to severe COVID-19 and death. Thus, controlling this excessive
inflammatory response might potentially prevent disease progression. Inhaled budesonide is a
low cost, safe (time censored), effective (number needed to treat of eight), simple, and widely
available therapeutic option, which can be of great help around the world, particularly in low-
income and middle-income countries [4]. Several potential mechanisms might underlie these
clinical observations. First, inhaled corticosteroids (including budesonide) have been used
successfully for decades to down regulate the excessive inflammation that characterises several
chronic airway diseases such as asthma and COPD,So it is plausible that inhaled budesonide
might have contributed to control the inflammatory response in early COVID-19, as systemic
dexamethasone seems to do in patients with severe COVID-19. In the context of the current
pandemic, it was noted that patients with asthma and COPD appear to be under-represented
among COVID-19-infected individuals seeking emergency care, and it was hypothesised that the
chronic use of inhaled corticosteroids might have controlled the excessive inflammatory
response induced by SARS-CoV-2 in these individuals [1,5].
MATERIAL & METHODS:
We undertook a rapid systematic review to evaluate the role of budesonide in covid-19 patients.
The review was conducted using the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) checklist in April 2020 . We searched PubMed, EMBASE, Scopus
and Google Scholar for relevant studies on (COVID-19 or SARS or MERS or coronavirus) and
budesonide.
RESULTS:
Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring
urgent care, emergency department consultation and hospitalization. Table 1 shows the ressearch
based review of inhaled budesonide and its effect on corona virus diseases.
TABLE 1: DATA BASED RESEARCH REVIEW ON ROLE OF INHALED
BUDESONIDE IN CORONA VIRUS DISEASE
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
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DISCUSSION:
Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring
urgent care, emergency department consultation and hospitalization.In vitro studies have
suggested that corticosteroids may impair antiviral innate immune responses [6,7] and that ICS
use leads to delayed virus clearance [9]. Other studies, however, have shown normal responses in
patients on ICS [10]. It is important to note that most studies have been carried out with
rhinovirus and there may be differences in the response to other viruses. Sanjay Ramakrishnan
from the Nuffield department of Clinical Medicine, University of Oxford, UK, and lead author of
the study, said the phase 2 clinical trial was done in the community in Oxfordshire, UK and the
aim was to evaluate the efficacy of the widely used inhaled glucocorticoid budesonide in
individuals with early Covid-19 infection in the community[11]. The onset of Covid-19 is
usually mild, providing a potential window to intervene before the development of severe
disease. From July 16 to December 9, 2020, 146 participants were randomly assigned — 73 to
usual care and 73 to budesonide. The study results showed that inhaled budesonide significantly
reduced the risk of urgent care visit, emergency department assessment or hospitalisation versus
the usual care arm by 91 percent. the trial participants were people with mild symptoms and did
not include those with severe symptoms or hospitalisation. The study concluded that the use of
inhaled budesonide in early mild cases has a 90 per cent chance of preventing hospitalization
[11.12]. In the Lancet study, patients in the budesonide arm received a budesonide dry powder
inhaler at a dose of 800 μg twice a day. Participants, administered budesonide, were asked to
stop taking the inhaler when they felt they had recovered or if they had a primary outcome .
Inhaled budesonide was taken for a median duration of seven days in the study. In the other
group, the usual care was supportive therapy, with the National Health Service (NHS) advising
patients with Covid-19 symptoms to take antipyretics for symptoms of fever (products
containing paracetamol, or non-steroidal anti-inflammatories such as aspirin and ibuprofen) and
S.NO. STUDY TYPE AUTHOR DETAILS DURATION SAMPLE RESULTS
1 Inhaled budesonide in
the treatment of early
COVID-19 illness
(STOIC): a phase 2,
open-label, randomised
controlled trial
Sanjay Ramakrishnan
from the Nuffield
department of Clinical
Medicine, University of
Oxford, UK
From July 16
to December
9, 2020
146 participants
were randomly
assigned — 73
to usual care and
73 to
budesonide.
The study concluded that
the use of inhaled
budesonide in early mild
cases has a 90 per cent
chance of preventing
hospitalization
2 Inhaled budesonide in
early treatment reduces
need for urgent medical
care,Lancet study
MascarenhasAnuradha. April 22,2021 Inhaled budesonide in
early Covid-19 infection
significantly reduced the
likelihood of requiring
urgent care, emergency
department consultation
and hospitalisation, the
study results showed.
3 Budesonide shortens
recovery time in patients
not admitted to hospital.
Elisabeth Mahase.Covid-
19
25 March
2021
751 people in
the budesonide
group (800 µg
twice a day for
14 days) and
1028 in the
usual care group
who were
SARS-CoV-2
positive
Inhaled budesonide
reduced the time to
recovery by a median of
three days in people with
Covid-19 with risk
factors for adverse
outcomes
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
4905
http://annalsofrscb.ro
honey for symptoms of cough. Inhaled budesonide in early Covid-19 infection significantly
reduced the likelihood of requiring urgent care, emergency department consultation and
hospitalisation, the study results showed.[4] In another updated interim, analysis (published in
medRxiv preprint by authors from the same group at Nuffield Department of Clinical Medicine
and Nuffield Department of Primary Care Health Sciences, University of Oxford) showed that
inhaled budesonide reduced the time to recovery by a median of three days in people with Covid-
19 with risk factors for adverse outcomes[18]. The interim analysis, based on data collected up to
25 March 2021, involved 751 people in the budesonide group (800 µg twice a day for 14 days)
and 1028 in the usual care group who were SARS-CoV-2 positive. It found that the median time
to self-reported recovery for people taking inhaled budesonide was 3.011 days shorter compared
with usual care (95% Bayesian credible interval 1.134 to 5.410 days), with a high probability
(0.999) of being superior to the usual standard of care[18]. Around one third (32%) of people
taking inhaled budesonide recovered in the first 14 days post-randomisation and remained well
until 28 days, compared with just over one fifth (22%) in the usual care group. The budesonide
group also reported greater wellbeing after two weeks (mean difference in WHO-5 wellbeing
score +3.37, 95% confidence interval 0.97 to 5.76, P=0.006). A rapid systematic review was
done to evaluate whether pre-morbid use or continued administration of inhaled steroids is a risk
factor for adverse outcomes in acute respiratory infections due to COVID-19, SARS or MERS.
The review was conducted using the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) checklist in March 2020 [21]. In total 771 publications were
identified by the search strategies. The abstracts of these publications were screened by two
reviewers (D.M.G. Halpin and D. Singh) and 59 publications were identified for full text review.
Following examination of the full texts including translations of those in Chinese, no
publications were identified as having data on prior ICS use in patients with SARS, MERS or
COVID-19 infection. A few studies did report the prevalence of comorbidities, including chronic
respiratory disease and occasionally specifically asthma or COPD, but in general studies
provided little or no information about patients’ pre-morbid health or medication.[22,23] Even if
data on the prevalence of ICS use had been available, their interpretation would have been
impossible without also having data on the severity of the underlying respiratory disease to allow
adjustment for this as a confounding factor.
CONCLUSION
The steroids in Covid-19 (STOIC) trial potentially provide the first easily accessible effective
intervention in early treatment of Covid-19. Inhaled budesonide in early Covid-19 infection
significantly reduced the likelihood of requiring urgent care, emergency department consultation
and hospitalization. The budesonide group also reported greater wellbeing of the patients after
two weeks . Inhaled Budesonide, a steroid used to treat asthma, if given early to Covid-
19 patients with mild symptoms, scales down the need for urgent medical care and reduces
recovery time.
REFERENCES
1. HALPIN D G,SINGH DAVE, HADFIELD.Inhaled corticosteroids and COVID-19: a systematic
review and clinical perspective, European Respiratory Journal 2020.
2. Wu Z, McGoogan JM.Characteristics of and Important Lessons From the Coronavirus
Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From
the Chinese Center for Disease Control and Prevention. JAMA 2020. Epub 2020/02/25.
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
4906
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3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel
coronavirus in Wuhan, China. Lancet 2020; 395: 497–506. Epub 2020/01/28.
4. MascarenhasAnuradha. Inhaled budesonide in early treatment reduces need for urgent
medical care, Lancet study: April 22,2021.
5. SchultzeA ,Walker AJ ,MacKenna B et al. Risk of COVID-19-related death among patients
with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an
observational cohort study using the OpenSAFELY platform. Lancet Respir
Med. 2020; 8: 1106-1120.
6. McKeever T, Harrison TW, Hubbard R, et al. . Inhaled corticosteroids and the risk of
pneumonia in people with asthma: a case–control study. Chest 2013; 144: 1788–1794.
7. Davies JM, Carroll ML, Li H, et al. . Budesonide and formoterol reduce early innate anti-
viral immune responses in vitro. PLoS One 2011; 6: e27898.
8. Simpson JL, Carroll M, Yang IA, et al. . Reduced antiviral interferon production in poorly
controlled asthma is associated with neutrophilic inflammation and high-dose inhaled
corticosteroids. Chest 2016; 149: 704–713.
9. Singanayagam A, Glanville N, Girkin JL, et al. . Corticosteroid suppression of antiviral
immunity increases bacterial loads and mucus production in COPD exacerbations. Nat
Commun 2018; 9: 2229.
10. Southworth T, Pattwell C, Khan N, et al. . Increased type 2 inflammation post rhinovirus
infection in patients with moderate asthma. Cytokine 2020; 125: 154857.
11. Ramakrishnan S ,Nicolau DV ,Langford B et al. Inhaled budesonide in the treatment of
early COVID-19 illness (STOIC): a phase 2, open-label, randomised controlled trial. Lancet
Respir Med. 2021; (published online April 9.)
12. MeghjiJ ,Mortimer K ,Agusti A et al. Improving lung health in low-income and middle-
income countries: from challenges to solutions. Lancet. 2021; 397: 928-94..
13. Emerson SS ,Kittelson JM, Gillen DL. Frequentist evaluation of group sequential clinical
trial designs.Stat Med. 2007; 26: 5047-5080.
14. Meghji J Mortimer K AgustiA et al. Improving lung health in low-income and middle-
income countries: from challenges to solutions. Lancet. 2021; 397: 928-940.
15. The RECOVERY Collaborative Group: Dexamethasone in hospitalized patients with
COVID-19.N Engl J Med. 2021; 384: 693-704
16. Peters MC ,Sajuthi S ,Deford P et al.COVID-19-related genes in sputum cells in asthma.
Relationship to demographic features and corticosteroids. Am J RespirCrit Care
Med. 2020; 202: 83-90
17. Finney LJ ,Glanville N, Farne H et al. Inhaled corticosteroids downregulate the SARS-CoV-
2 receptor ACE2 in COPD through suppression of type I interferon.J Allergy
ClinImmunol. 2021; 147: 510-519.
18. Brodin P:Immune determinants of COVID-19 disease presentation and severity. Nat
Med. 2021; 27: 28-33.
19. Elisabeth Mahase.Covid-19: Budesonide shortens recovery time in patients not admitted to
hospital.BMJ 2021; 373.
20. Brodin P:Immune determinants of COVID-19 disease presentation and severity. Nat
Med. 2021; 27: 28-33.
21. Moher D, Liberati A, Tetzlaff J, et al. . Preferred reporting items for systematic reviews
and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907
Received 25 April 2021; Accepted 08 May 2021.
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22. A trial of ciclesonide in adults with mild COVID-19. NCT04330586
https://clinicaltrials.gov/ct2/show/NCT04330586 Date last updated: 1 April 2020.
23. Protective Role of Inhaled Steroids for Covid-19 Infection (INHASCO). NCT04331054
https://clinicaltrials.gov/ct2/show/NCT04331054 Date last updated: 17 April 2020.

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Role of Budesonide in Corona Virus Disease: Systematic Review

  • 1. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4902 http://annalsofrscb.ro Role of Budesonide in Corona Virus Disease: Systematic Review Dr. BalaYaduVamsi Sankuratri1 , Dr. Rahul VC Tiwari2 , Dr. Aarushi Shekhar3 , Dr. Abhimanyu Singh4 , Dr. AjithBabu Poovathingal5 , Dr. MyleshRavisankar Dakshinamurthy6 , Dr. Heena Tiwari7 1 BDS, MPH, University of Texas at Arlington, Texas. byv.sankuratri@gmail.com; 2 OMFS, FOGS, PhD Scholar, Dept of OMFS, Narsinbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat,384315. drrahulvctiwari@gmail.com; 3 P.G Student , Department of Conservative and Endodontic Dentistry, BabuBanarasi Das College of Dental Science, Lucknow. aarushishekhar367@gmail.com; 4 P.G student, Department of Pediatric and Preventive Dentistry, Saraswati Dental College, Lucknow. abhimanyusingh.2405@gmail.com; 5 MBBS MD, Internal Medicine Registrar at Unity Hospital, Kanipayoor, Thrissur district, Kerala. ajithbabu13@gmail.com; 6 4th year MBBS student at Yerevan State Medical University, Yerevan, Armenia. myleshravisankar@gmail.com; 7 BDS, PGDHHM, MPH Student, ParulUniveristy, Limda, Waghodia, Vadodara, Gujrat, India.drheenatiwari@gmail.com Corresponding Author: Dr. BalaYaduVamsiSankuratri, BDS, MPH, University of Texas at Arlington, Texas. byv.sankuratri@gmail.com ABSTRACT: Background: The current COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, raises important questions as to whether pre-morbid use or continued administration of inhaled corticosteroids (ICS) affects the outcomes of acute respiratory infections due to coronavirus. Purpose of study:Inhaled budesonide is a low cost, safe (time censored), effective (number needed to treat of eight) simple and widely available therapeutic option, which can be of great help around the world, particularly in low-income and middle-income countries. Several potential mechanisms might underlie these clinical observations. Results: Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalization. Conclusion: The budesonide group reported greater wellbeing of the patients. Also scales down the need for urgent medical care and reduces recovery time, if given early to Covid-19 patients with mild symptoms. Key Words: Budesonide, COVID, Corona Virus. INTRODUCTION The current COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, raises important questions as to whether pre-morbid use or continued administration of inhaled corticosteroids (ICS) affects the outcomes of acute respiratory infections due to coronavirus[1]. In most individuals, infection with SARS-CoV-2 is either
  • 2. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4903 http://annalsofrscb.ro asymptomatic or produces mild illness (COVID-19) that resolves spontaneously; yet, a small proportion of patients with COVID-19 develop severe disease, require hospitalisation (often in a critical-care setting) and die. COVID-19 has an initial period characterised by cough and fever, followed after around 8 days in approximately 20% of patients by the development of dyspnoea with pulmonary infiltrates in about 10% [2,3]. Approximately a quarter of patients admitted to hospital developed acute respiratory distress syndrome (ARDS) after a median of 10.5 days after symptom onset [3]. A dysregulated type I interferon response to SARS-CoV-2 with overproduction of proinflammatory cytokines seems to be a key pathogenic mechanism underlying progression to severe COVID-19 and death. Thus, controlling this excessive inflammatory response might potentially prevent disease progression. Inhaled budesonide is a low cost, safe (time censored), effective (number needed to treat of eight), simple, and widely available therapeutic option, which can be of great help around the world, particularly in low- income and middle-income countries [4]. Several potential mechanisms might underlie these clinical observations. First, inhaled corticosteroids (including budesonide) have been used successfully for decades to down regulate the excessive inflammation that characterises several chronic airway diseases such as asthma and COPD,So it is plausible that inhaled budesonide might have contributed to control the inflammatory response in early COVID-19, as systemic dexamethasone seems to do in patients with severe COVID-19. In the context of the current pandemic, it was noted that patients with asthma and COPD appear to be under-represented among COVID-19-infected individuals seeking emergency care, and it was hypothesised that the chronic use of inhaled corticosteroids might have controlled the excessive inflammatory response induced by SARS-CoV-2 in these individuals [1,5]. MATERIAL & METHODS: We undertook a rapid systematic review to evaluate the role of budesonide in covid-19 patients. The review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist in April 2020 . We searched PubMed, EMBASE, Scopus and Google Scholar for relevant studies on (COVID-19 or SARS or MERS or coronavirus) and budesonide. RESULTS: Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalization. Table 1 shows the ressearch based review of inhaled budesonide and its effect on corona virus diseases. TABLE 1: DATA BASED RESEARCH REVIEW ON ROLE OF INHALED BUDESONIDE IN CORONA VIRUS DISEASE
  • 3. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4904 http://annalsofrscb.ro DISCUSSION: Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalization.In vitro studies have suggested that corticosteroids may impair antiviral innate immune responses [6,7] and that ICS use leads to delayed virus clearance [9]. Other studies, however, have shown normal responses in patients on ICS [10]. It is important to note that most studies have been carried out with rhinovirus and there may be differences in the response to other viruses. Sanjay Ramakrishnan from the Nuffield department of Clinical Medicine, University of Oxford, UK, and lead author of the study, said the phase 2 clinical trial was done in the community in Oxfordshire, UK and the aim was to evaluate the efficacy of the widely used inhaled glucocorticoid budesonide in individuals with early Covid-19 infection in the community[11]. The onset of Covid-19 is usually mild, providing a potential window to intervene before the development of severe disease. From July 16 to December 9, 2020, 146 participants were randomly assigned — 73 to usual care and 73 to budesonide. The study results showed that inhaled budesonide significantly reduced the risk of urgent care visit, emergency department assessment or hospitalisation versus the usual care arm by 91 percent. the trial participants were people with mild symptoms and did not include those with severe symptoms or hospitalisation. The study concluded that the use of inhaled budesonide in early mild cases has a 90 per cent chance of preventing hospitalization [11.12]. In the Lancet study, patients in the budesonide arm received a budesonide dry powder inhaler at a dose of 800 μg twice a day. Participants, administered budesonide, were asked to stop taking the inhaler when they felt they had recovered or if they had a primary outcome . Inhaled budesonide was taken for a median duration of seven days in the study. In the other group, the usual care was supportive therapy, with the National Health Service (NHS) advising patients with Covid-19 symptoms to take antipyretics for symptoms of fever (products containing paracetamol, or non-steroidal anti-inflammatories such as aspirin and ibuprofen) and S.NO. STUDY TYPE AUTHOR DETAILS DURATION SAMPLE RESULTS 1 Inhaled budesonide in the treatment of early COVID-19 illness (STOIC): a phase 2, open-label, randomised controlled trial Sanjay Ramakrishnan from the Nuffield department of Clinical Medicine, University of Oxford, UK From July 16 to December 9, 2020 146 participants were randomly assigned — 73 to usual care and 73 to budesonide. The study concluded that the use of inhaled budesonide in early mild cases has a 90 per cent chance of preventing hospitalization 2 Inhaled budesonide in early treatment reduces need for urgent medical care,Lancet study MascarenhasAnuradha. April 22,2021 Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalisation, the study results showed. 3 Budesonide shortens recovery time in patients not admitted to hospital. Elisabeth Mahase.Covid- 19 25 March 2021 751 people in the budesonide group (800 µg twice a day for 14 days) and 1028 in the usual care group who were SARS-CoV-2 positive Inhaled budesonide reduced the time to recovery by a median of three days in people with Covid-19 with risk factors for adverse outcomes
  • 4. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4905 http://annalsofrscb.ro honey for symptoms of cough. Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalisation, the study results showed.[4] In another updated interim, analysis (published in medRxiv preprint by authors from the same group at Nuffield Department of Clinical Medicine and Nuffield Department of Primary Care Health Sciences, University of Oxford) showed that inhaled budesonide reduced the time to recovery by a median of three days in people with Covid- 19 with risk factors for adverse outcomes[18]. The interim analysis, based on data collected up to 25 March 2021, involved 751 people in the budesonide group (800 µg twice a day for 14 days) and 1028 in the usual care group who were SARS-CoV-2 positive. It found that the median time to self-reported recovery for people taking inhaled budesonide was 3.011 days shorter compared with usual care (95% Bayesian credible interval 1.134 to 5.410 days), with a high probability (0.999) of being superior to the usual standard of care[18]. Around one third (32%) of people taking inhaled budesonide recovered in the first 14 days post-randomisation and remained well until 28 days, compared with just over one fifth (22%) in the usual care group. The budesonide group also reported greater wellbeing after two weeks (mean difference in WHO-5 wellbeing score +3.37, 95% confidence interval 0.97 to 5.76, P=0.006). A rapid systematic review was done to evaluate whether pre-morbid use or continued administration of inhaled steroids is a risk factor for adverse outcomes in acute respiratory infections due to COVID-19, SARS or MERS. The review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist in March 2020 [21]. In total 771 publications were identified by the search strategies. The abstracts of these publications were screened by two reviewers (D.M.G. Halpin and D. Singh) and 59 publications were identified for full text review. Following examination of the full texts including translations of those in Chinese, no publications were identified as having data on prior ICS use in patients with SARS, MERS or COVID-19 infection. A few studies did report the prevalence of comorbidities, including chronic respiratory disease and occasionally specifically asthma or COPD, but in general studies provided little or no information about patients’ pre-morbid health or medication.[22,23] Even if data on the prevalence of ICS use had been available, their interpretation would have been impossible without also having data on the severity of the underlying respiratory disease to allow adjustment for this as a confounding factor. CONCLUSION The steroids in Covid-19 (STOIC) trial potentially provide the first easily accessible effective intervention in early treatment of Covid-19. Inhaled budesonide in early Covid-19 infection significantly reduced the likelihood of requiring urgent care, emergency department consultation and hospitalization. The budesonide group also reported greater wellbeing of the patients after two weeks . Inhaled Budesonide, a steroid used to treat asthma, if given early to Covid- 19 patients with mild symptoms, scales down the need for urgent medical care and reduces recovery time. REFERENCES 1. HALPIN D G,SINGH DAVE, HADFIELD.Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective, European Respiratory Journal 2020. 2. Wu Z, McGoogan JM.Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020. Epub 2020/02/25.
  • 5. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4906 http://annalsofrscb.ro 3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497–506. Epub 2020/01/28. 4. MascarenhasAnuradha. Inhaled budesonide in early treatment reduces need for urgent medical care, Lancet study: April 22,2021. 5. SchultzeA ,Walker AJ ,MacKenna B et al. Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform. Lancet Respir Med. 2020; 8: 1106-1120. 6. McKeever T, Harrison TW, Hubbard R, et al. . Inhaled corticosteroids and the risk of pneumonia in people with asthma: a case–control study. Chest 2013; 144: 1788–1794. 7. Davies JM, Carroll ML, Li H, et al. . Budesonide and formoterol reduce early innate anti- viral immune responses in vitro. PLoS One 2011; 6: e27898. 8. Simpson JL, Carroll M, Yang IA, et al. . Reduced antiviral interferon production in poorly controlled asthma is associated with neutrophilic inflammation and high-dose inhaled corticosteroids. Chest 2016; 149: 704–713. 9. Singanayagam A, Glanville N, Girkin JL, et al. . Corticosteroid suppression of antiviral immunity increases bacterial loads and mucus production in COPD exacerbations. Nat Commun 2018; 9: 2229. 10. Southworth T, Pattwell C, Khan N, et al. . Increased type 2 inflammation post rhinovirus infection in patients with moderate asthma. Cytokine 2020; 125: 154857. 11. Ramakrishnan S ,Nicolau DV ,Langford B et al. Inhaled budesonide in the treatment of early COVID-19 illness (STOIC): a phase 2, open-label, randomised controlled trial. Lancet Respir Med. 2021; (published online April 9.) 12. MeghjiJ ,Mortimer K ,Agusti A et al. Improving lung health in low-income and middle- income countries: from challenges to solutions. Lancet. 2021; 397: 928-94.. 13. Emerson SS ,Kittelson JM, Gillen DL. Frequentist evaluation of group sequential clinical trial designs.Stat Med. 2007; 26: 5047-5080. 14. Meghji J Mortimer K AgustiA et al. Improving lung health in low-income and middle- income countries: from challenges to solutions. Lancet. 2021; 397: 928-940. 15. The RECOVERY Collaborative Group: Dexamethasone in hospitalized patients with COVID-19.N Engl J Med. 2021; 384: 693-704 16. Peters MC ,Sajuthi S ,Deford P et al.COVID-19-related genes in sputum cells in asthma. Relationship to demographic features and corticosteroids. Am J RespirCrit Care Med. 2020; 202: 83-90 17. Finney LJ ,Glanville N, Farne H et al. Inhaled corticosteroids downregulate the SARS-CoV- 2 receptor ACE2 in COPD through suppression of type I interferon.J Allergy ClinImmunol. 2021; 147: 510-519. 18. Brodin P:Immune determinants of COVID-19 disease presentation and severity. Nat Med. 2021; 27: 28-33. 19. Elisabeth Mahase.Covid-19: Budesonide shortens recovery time in patients not admitted to hospital.BMJ 2021; 373. 20. Brodin P:Immune determinants of COVID-19 disease presentation and severity. Nat Med. 2021; 27: 28-33. 21. Moher D, Liberati A, Tetzlaff J, et al. . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
  • 6. Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 4902 - 4907 Received 25 April 2021; Accepted 08 May 2021. 4907 http://annalsofrscb.ro 22. A trial of ciclesonide in adults with mild COVID-19. NCT04330586 https://clinicaltrials.gov/ct2/show/NCT04330586 Date last updated: 1 April 2020. 23. Protective Role of Inhaled Steroids for Covid-19 Infection (INHASCO). NCT04331054 https://clinicaltrials.gov/ct2/show/NCT04331054 Date last updated: 17 April 2020.