Corticosteroid Use in Influenza Infection: Recommendations

Evidencia sobre corticosteroides en influenza

• Los análisis de 13 estudios observacionales (n=1.917 pacientes) encontraron un odds ratio (OR) de mortalidad de 3,06 (IC 95%: 1,58-5,92) en contra del uso de corticosteroides en influenza 1, 2, 3
• El análisis de cuatro ensayos con bajo riesgo de sesgo reveló hallazgos consistentes (OR: 2,82; IC 95%: 1,61-4,92) y un mayor riesgo de sobreinfección 1, 2
• Estudios previos han demostrado poco beneficio del uso de glucocorticoides en el tratamiento de SARS-CoV-1, MERS, influenza o virus sincitial respiratorio 4, 5
• El tratamiento con glucocorticoides en neumonía por influenza se ha asociado con resultados significativamente peores, incluyendo mayor mortalidad, más infecciones bacterianas secundarias y aumento en la duración de la estancia en UCI 6, 7

Consideraciones importantes

• Los corticosteroides pueden aumentar el riesgo de infección secundaria y retrasar la eliminación viral en infecciones respiratorias 4, 5

Situaciones especiales a considerar

• En pacientes con enfermedades reumáticas que desarrollan influenza sintomática, se debe continuar con los glucocorticoides, pero con un esfuerzo por reducir la dosis al nivel más bajo posible para controlar la enfermedad subyacente y evitar la insuficiencia suprarrenal 8, 9
• Se debe evitar la suspensión abrupta de glucocorticoides debido al riesgo de desarrollar supresión adrenal, especialmente en pacientes que reciben >5 mg/día de prednisona o equivalente 5, 10

Advertencias y precauciones

• La suspensión abrupta de corticosteroides en pacientes que los han estado tomando crónicamente puede provocar insuficiencia suprarrenal aguda 5, 10
• Si el paciente ha estado tomando corticosteroides a largo plazo, considere reducir gradualmente la dosis en lugar de suspender abruptamente 8
• En casos de enfermedad reumática con manifestaciones graves que amenazan la vida o los órganos, los beneficios de mantener los corticosteroides pueden superar los riesgos, incluso en presencia de influenza 8, 9

Corticosteroid Use in Influenza Treatment

Primary Recommendation

• The Infectious Diseases Society of America (IDSA) recommends that clinicians should not administer corticosteroid adjunctive therapy for adults or children with suspected or confirmed seasonal influenza, unless clinically indicated for other reasons, with an A-III recommendation 11, 12
• The IDSA explicitly states that corticosteroids should not be administered for the treatment of seasonal influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons 11, 12

Evidence Supporting This Recommendation

• The use of corticosteroids in influenza treatment may delay viral clearance, according to The Lancet Respiratory Medicine 13

Proper Management Algorithm for Influenza

• The IDSA recommends immediate antiviral therapy with neuraminidase inhibitors as soon as possible, regardless of time since symptom onset in severe cases, and empiric antibacterial coverage for patients presenting with severe disease 11, 12
• Investigation of bacterial coinfection is recommended in patients who deteriorate after initial improvement or fail to improve after 3-5 days of antiviral treatment 11, 12

Management of Influenza in Patients Taking Prednisone

Critical Evidence Against Adding Corticosteroids for Influenza

• Meta-analysis of Asian cohorts demonstrated corticosteroid therapy was associated with superinfection and increased mortality in seasonal and pandemic influenza 14

Vaccination Considerations

• The American College of Rheumatology suggests considering measuring pathogen-specific antibody concentrations after vaccination in patients on high-dose glucocorticoids, as high-dose steroids may blunt vaccine immunogenicity 15

Effects of Corticosteroids on Viral Clearance and Mortality in Severe Respiratory Viral Infections

Viral Clearance

• In a retrospective cohort of roughly 300 ICU patients with a severe respiratory viral infection (MERS), corticosteroid therapy was associated with delayed viral clearance and did not improve survival, suggesting that immunosuppression may be harmful during active viral replication. 16

Mortality and Oxygenation

• A small observational study of critically ill patients with influenza‑associated ARDS found that corticosteroids produced a transient rise in the PaO₂/FiO₂ ratio during the first 3–5 days, but there was no reduction in overall mortality (≈ 47 %) and no survival benefit was observed. 16

Corticosteroid Use in Post‑Viral Influenza ARDS – Evidence‑Based Recommendations

Harm Associated with Corticosteroids

Guideline Recommendations Against Routine Steroid Use

Exceptions: When Steroids May Be Appropriate

Adjunctive ARDS Management (Non‑Steroid Strategies)

Misinterpretation of COVID‑19 Steroid Data