Acute 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.
Patients requiring supplemental oxygen delivered by standard nasal canula
  • Corticosteroids could be considered on a case-by-case basis, weighing individual risks and benefits and duration of illness, with children who have been ill for longer durations (e.g., more than 7-10 days) perhaps benefiting more. While the RECOVERY   demonstrated a reduction in mortality with steroid use in patients requiring supplemental oxygen, it is 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 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.
  • If the patient is being treated for an asthma exacerbation in the setting of COVID-19, we suggest methylprednisolone 2 mg/kg/day divided twice daily (max: 30 mg/dose) per the asthma pathway. Extension of steroid duration beyond 5 days with ongoing methylprednisolone or transition to dexamethasone should be determined on a case-by-case basis.
Patients requiring invasive or non-invasive mechanical ventilation (including high flow nasal canula)
  • Corticosteroids are suggested for patients 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.
  • If the patient is being treated for an asthma exacerbation in the setting of COVID-19, we suggest methylprednisolone 2 mg/kg/day divided twice daily (max: 30 mg/dose) per the asthma pathway. Extension of steroid duration beyond 5 days with ongoing methylprednisolone or transition to dexamethasone should be determined on a case-by-case basis.
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)