Active COVID-19, Clinical Pathway — All Settings

Steroid use for COVID-19
COVID-19 (+) patients with asthma exacerbations
Recommend use of corticosteroids, per the asthma pathway. Note that the dose of methylprednisolone recommended for asthma of 2 mg/kg/day divided twice daily (max: 30 mg/dose) per the asthma pathway exceeds the equivalent dose of dexamethasone recommended for COVID-19 pneumonia. Therefore, if a patient is being treated for asthma in the setting of COVID-19, it is important to follow usual practice surrounding initiation and dosing of steroids for asthma. The recommended duration of steroids for COVID-19 is up to 10 days; extension of steroid duration beyond 5 days with ongoing methylprednisolone or transition to dexamethasone should be determined on a case-by-case basis but is likely not necessary in most patients.
COVID-19 (+) patients with bronchiolitis
There are no COVID-19 specific clinical data supporting use of steroids in infants and young children with bronchiolitis. Because of the self-limited nature of this condition, the lack of benefit of steroids in bronchiolitis of other etiologies, and the multifactorial reasons for hypoxia in bronchiolitis, steroids are not routinely recommended in this group, particularly for those on low flow oxygen.
Patients requiring supplemental oxygen delivered by standard nasal canula
  • Corticosteroids are not routinely recommended, but could be considered on a case-by-case basis, weighing individual risks and benefits. Patients more likely to benefit from steroids include those who have longer duration of illness (e.g., more than 7-10 days), older children/adolescents, and patients with escalating supplemental oxygen needs. The rationale for this recommendation is that the RECOVERY   trial demonstrated a reduction in mortality with steroid use in patients requiring supplemental oxygen, but this group was heterogeneous in the populations included (i.e., patients on low flow, high flow, and non-invasive mechanical ventilation). It is also unclear whether these findings can be generalized to children given the overall milder illness severity in this group. The NIH COVID-19 guidelines recommend considering corticosteroids in children on low flow oxygen on a case-by-case basis.
  • If corticosteroids are used, we suggest dexamethasone with the following dosing for most patients:
    • Dexamethasone 0.15 mg/kg/dose (max: 6 mg daily) for up to 10 days. Dexamethasone should be stopped at discharge (unless there is another indication for ongoing corticosteroids), and may be stopped earlier for hospitalized patients who improve rapidly and no longer require supplemental oxygen.
Patients requiring invasive or non-invasive mechanical ventilation (including high flow nasal canula)
  • Corticosteroids are suggested for patients with COVID-19 lower respiratory tract disease requiring invasive or non-invasive mechanical ventilation, unless there are contraindications, particularly for those with ARDS. The RECOVERY   trial demonstrated reductions in mortality with dexamethasone use in hospitalized adults, and use of steroids in children requiring invasive or non-invasive mechanical ventilation is suggested by the NIH COVID-19 guideline.
  • If corticosteroids are used, we suggest dexamethasone with the following dosing: Dexamethasone 0.15 mg/kg/dose IV/PO every 24 hours (max: 6 mg daily) for up to 10 days. Dexamethasone should be stopped at discharge (unless there is another indication for ongoing corticosteroids), and may be stopped earlier for hospitalized patients who improve rapidly and no longer require supplemental oxygen.
Catecholamine-refractory septic shock
Recommend use of corticosteroids, per WHO and SCCM COVID guidelines for catecholamine refractory septic shock. Dexamethasone 0.15 mg/kg/dose (max: 6mg) daily provides adequate steroid exposure for patients without adrenal insufficiency, if dexamethasone is otherwise being prescribed based on the recommendations above. For patients with adrenal insufficiency, hydrocortisone should be administered in addition to dexamethasone. Patients not receiving dexamethasone based on the indications above should receive hydrocortisone.
  • Hydrocortisone dosing
    • BSA-based dosing
      Hydrocortisone 100 mg/m2 load (max: 100 mg), then 100 mg/m2/day divided q6 hours IV (max: 25 mg/dose)
    • Mg/kg-based dosing
      Hydrocortisone 2 mg/kg IV load (max 100 mg), then 2 mg/kg/day divided q6 hours IV
      (max: 25 mg/dose)
Steroid choice
  Baseline adrenal insufficiency No baseline adrenal insufficiency
Receiving dexamethasone for lung disease Hydrocortisone
+
Dexamethasone		 Dexamethasone
Not receiving dexamethasone for lung disease Hydrocortisone Hydrocortisone
Adrenal insufficiency
Patients who are adrenally insufficient should receive stress dose steroids per usual routine and duration (see also steroid stress dosing pathway). If dexamethasone is additionally indicated, hydrocortisone should be administered in addition to dexamethasone.
Steroid choice
Severity Initial dose Subsequent doses
Severe 100 mg/m2 IV/IM (Max: 100 mg)

IV: 100 mg/m2/day divided every 6 hours (max: 25 mg/dose)

Oral: 100 mg/m2/day divided every 8 hours (max: 40 mg/dose)
Moderate No initial dosing

IV: 50 mg/m2/day divided every 6 hours
(max dose: 12.5 mg/dose)

Oral: 50 mg/m2/day divided every 8 hours
(max dose: 20 mg/dose)
  • Mg/kg-based dosing (severe stress)
    Hydrocortisone 2 mg/kg IV load (max 100 mg), then 2 mg/kg/day divided q6 hours IV
    (max: 25 mg/dose)