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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 2-5

Steroid therapy in swine flu: Beneficial or harmful


Department of Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Krittibus Samui
C/O Tapan Kumar Samui, Jilipi Bagan Near, Atachaki, P.O. - Sripally, Burdwan - 713 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_14_18

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  Abstract 

H1N1 influenza virus is responsible for respiratory illness that may range from mild symptoms of common cold to severe disease on presentation that needs hospitalization and management in intensive care. Corticosteroids are used to treat disease of immunity, inflammation or salt, and water balance. Here, the role of corticosteroid in swine flu is reviewed in various literatures. It is found that result of corticosteroid use in the management of swine flu patients is unsatisfactory. Instead of benefit, it is potentially harmful. It causes to develop higher duration of hospital stay, prolonged mechanical ventilation and ultimately increased mortality.

Keywords: Hospital stay, influenza, mortality, ventilation


How to cite this article:
Samui K. Steroid therapy in swine flu: Beneficial or harmful. Apollo Med 2018;15:2-5

How to cite this URL:
Samui K. Steroid therapy in swine flu: Beneficial or harmful. Apollo Med [serial online] 2018 [cited 2018 Aug 16];15:2-5. Available from: http://www.apollomedicine.org/text.asp?2018/15/1/2/229051


  Introduction Top


The first cases of swine flu virus during pandemic were reported on April 21 in California and in Mexico on April 23, 2009.[1] The first case in India was reported on May 13, 2009, in Hyderabad. The World Health Organization declared influenza A (H1N1) as pandemic influenza in mid-year of 2009.[2],[3],[4] Seasonal influenza infects in children, but it causes less mortality. However, it predominantly infects people older than 65 years of age.[5] However, children were disproportionately infected by pandemic influenza A (H1N1) more than older age-groups in 2009.[6] Risk factors for severe pandemic H1N1 infection and seasonal influenza are similar except younger age and obesity which have the highest risk of severe outcomes.[7] Influenza has a notable mortality burden worldwide.[8],[9],[10],[11] Clinical features include fever, cough, sore throat, hoarseness, malaise, muscular pain, loose motion and vomiting, arthralgia, chills and headaches with ophthalmalgia, photophobia, etc. Complications may happen such as bronchitis, pneumonia, myocarditis, pericarditis, encephalitis, and shock affecting mainly in people with immune system compromise.[12] Delayed antiviral treatment, severe hypoxemia, and multisystem organ failure significantly affect critically ill patients with influenza.[13] In the recent years, oseltamivir, a neuraminidase inhibitor, is being extensively used after being stockpiled by multiple governments. Using randomized controlled trials, it is found that the drug had very limited benefit on preventing complications and viral transmission.[14],[15] It also reduces the duration of clinical symptoms by about half a day only.[16] Corticosteroid is a class of drug based on hormones formed from adrenal gland, which is used to reduce inflammatory activity. However, steroid can cause increased appetite, weight gain, neuropsychiatric change, muscle weakness, blurred vision, increased growth of body hair, easy bruising, lower resistance to infection, puffy face, acne, osteoporosis, worsening of diabetes, high blood pressure, stomach irritation, nervousness, restlessness, difficulty in sleeping, cataracts or glaucoma, water retention, swelling, etc., Here, we will discuss about the role of steroid therapy in patients of H1N1 influenza whether it is beneficial or harmful.


  Methods Top


In clinical practice, it is found that some clinicians prefer to give steroid in the management of selective patients who are normal individuals and have developed swine flu pneumonia. Some clinicians do not prefer to give steroid at all in the management of isolated H1N1 pneumonia without any known comorbidity. A fair number of standard literatures on the role of steroid therapy in swine flu are studied. Their results have been discussed here, and a conclusion is drawn based on literature review.


  Discussion Top


Corticosteroids favor spread of infections because of decreased capacity of defensive cells to kill microorganisms. They also interfere with healing and scar formation, peptic ulcer with asymptomatic perforation. Indiscriminate use of this group of drugs is hazardous. They suppress cell-mediated immunity in which T-cells are primarily involved. There may be inhibition of interleukin-1 (IL-1) release from macrophages, inhibition of lL-2 formation, inhibition of T-cell proliferation, and suppression of natural killer cells. Immunosuppression in the body has many adverse effects. Hence, it should be used cautiously in clinical practice. Study by Rewar et al. reported that high dose corticosteroids, in particular, did not cause any benefit, rather it harmed patients. However, low-dose corticosteroids (hydrocortisone 200–400 mg/day) might be used in persisting septic shock (systolic blood pressure <90 mm hg).[17] Rodrigo et al. found that adjunctive corticosteroid therapy increased mortality. They did not find sufficient evidence to determine the effectiveness of corticosteroids for patients with influenza.[18] Brun-Buisson et al. studied 208 acute respiratory failure patients. On receiving corticosteroid, mortality and the risk of hospital-acquired pneumonia increased to develop particularly, an early receiving group within 3 days after mechanical ventilation.[19] Linko et al. prospectively found the same mortality of two groups of patients who received and did not receive corticosteroid among the influenza confirmed patients in intensive care unit during the pandemic influenza in 2009.[20] Mady et al. study observed increased mortality of three times in pandemic influenza patients admitted to intensive care unit in 2009.[21] A study by the European Society of Intensive Care Medicine showed that corticosteroid use resulted in the development of high risk of hospital-acquired pneumonia.[22] Study by Kawashima et al. in Japan reported no benefit on steroid therapy among pediatric influenza encephalopathy patients.[23] In a lot of clinical case series and reports, critically ill patients developing pneumonia and encephalopathy improved with administration of corticosteroid.[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] Interesting thing was that all the studies showed negative result in patients of pandemic swine flu in 2009. Maraví-Poma et al. reported higher mortality in corticosteroid administration group compared to nonadministration group among severe influenza diseased pregnant women although this difference was not very statistically significant.[35] Han et al. observed higher mortality in the early administration group of corticosteroid (within 72 h of influenza symptoms) compared to delayed receiving and nonreceiving group of corticosteroid.[36] Diaz et al. study on viral pneumonia did not find any beneficial effect for steroid.[37] As per Kudo et al. study, systemic administration of corticosteroids along with early administration of antiviral agents may prevent progression to severe pneumonia in a population of H1N1 pneumonia irrespective of the presence of wheeze.[38] Delaney et al. found significant increased risk of death associated with corticosteroids in patients with H1N1 influenza.[39] Yang et al. observed that management with corticosteroid for patients with influenza virus infection has no better outcomes and may increase mortality and nosocomial infections. It also prolongs the duration of mechanical ventilation and intensive care unit stay.[40] Brun-Buisson et al. study provided no evidence of a beneficial effect of steroids in patients with acute respiratory distress syndrome secondary to influenza pneumonia. It also suggested the harmfulness of early corticosteroid therapy.[19] Meta-analysis by Zhang et al. did not support to use corticosteroids as standard care for patients with severe influenza.[41] As per Kim et al. study, adjuvant corticosteroids significantly increased higher mortality in critically ill patients with H1N1 influenza.[42] A study by Nedel et al. concluded that beneficial effects of corticosteroid therapy did not exist at all. It increased overall mortality. It might be associated with higher chances of development of hospital-acquired pneumonia, longer duration of mechanical ventilation, and intensive care unit stay.[43]

Corticosteroid drugs have anti-inflammatory action. They can reduce exudation, increased capillary permeability, cellular infiltration, phagocytic activity, and also the late responses such as capillary proliferation, collagen deposition, activation of fibroblast, and scar formation. Quispe-Laime et al. suggested the use of a low to moderate dose of a steroid.[44] Logic was that it may significantly improve lung injuries. However, this study was done with small size of the study populations. Sohn et al. reported that the corticosteroid therapy increased recovery to all 37 pediatric patients presenting exacerbating influenza pneumonia after administering within 48 h of presentation.[45] Kil et al. also observed that the duration of fever decreased, the necessity of oxygen therapy were significantly less and the number of cure rate from severe influenza pneumonia was greater in pediatric group of patients where steroid was administered.[46] However, the sample of the study population of both these two studied was small and the patients were limited to pediatric age group.

However, it is difficult to say fairly about the effect according to the dose, giving time and baseline of steroid use. Steroid usage is variable by physicians. Only a few numbers of previous studies have been found to give information in detail. Hence, further randomized clinical study is needed to specify the matter.


  Conclusion Top


Corticosteroid should not be used routinely in patients with swine flu except in conditions like associated obstructive airway disease, adrenal insufficiency where the therapeutic effect of steroid has already been proven. The use of steroid in normal individuals developed swine flu may increase prolongation of mechanical ventilation, duration of intensive care unit stay, and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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