In the Journals: Treating the Different Stages of COVID-19

COVID-19 can be divided into two stages. In the first stage, virus replication is predominant. At this stage, biologicals or drugs that inhibit viral replication, such as monoclonal antibodies, convalescent antiserum and Paxlovid™, have been shown to decrease progression to severe disease. In the second stage of COVID-19, the immune response takes over. During this stage, medications that suppress the immune system, like dexamethasone or tocilizumab, have been shown to decrease progression to severe disease. But, as has now been shown in many studies, drugs that suppress the immune system, if given during the first phase of illness, might be harmful, and drugs or biologicals that suppress viral replication during the second stage, when viral replication is no longer part of disease pathogenesis, have been useless.

Recently, researchers from several medical centers in the northeast performed a study to determine whether a topical steroid (fluticasone), administered intranasally early in infection, could affect disease progression (Boulware DR, Lindsell CJ, Stewart TG, et al. Inhaled Fluticasone, Furoate for Outpatient Treatment for Covid-19. N Engl J Med. 2023 Sep 21;389(12):1085-1095). About 1,300 COVID-19 patients were randomly assigned to receive either fluticasone once daily for 14 days or placebo. All patients had suffered at least two symptoms for less than seven days prior to entry in the study. The primary outcome was time to sustained recovery, defined as the absence of symptoms for at least three days. The authors found that “Treatment with inhaled fluticasone furoate for 14 days did not result in a shorter time to recovery than placebo among outpatients with Covid-19 in the United States.” This study again confirms the lack of efficacy of a steroid early in infection with SARS-CoV-2 virus.