Doctors and public health experts have sounded the alarm on unnecessary use of steroid therapy in treating Covid19, noting that its application in mild cases is triggering side-effects like viral pneumonia and mucormycosis during post-Covid recovery.

Steroids like dexamethasone help in reducing lung inflammation among Covid19 patients at the stage when the virus is replicating, if used correctly. But indiscriminate use of steroids is leading to complications among patients as they compromise the immune system. Experts thus note the importance of knowing when to take steroids and the right dosage.

Steroid therapy is useful after the patient becomes hypoxic — that is, when the patient begins to become deprived of oxygen. “If given early, before your saturation (O2) falls, it has a harmful effect. Covid patients who got steroids early had higher mortality than those who didn’t,” said All India Institute of Medical Science (AIIMS) director Dr. Randeep Guleria at a briefing.

Moreover, steroids should be avoided during the initial five days of infection. In the first week of the illness, when the virus is dividing, the use of steroids can suppress the immune response and make the virus divide more, experts say. “We have to understand that taking steroids at the early stage can give more stimulus to virus replication,” Dr. Guleria adds. “In many cases, mild cases are becoming severe and patients are reporting severe pneumonia.”

The ideal time is when oxygen is falling in moderate to severe cases, and giving steroids at small doses and for short durations (such as five days) can help. “Harmful if given early, or given for too long,” Vincent Rajkumar, M.D., a researcher at Mayo Clinic in the U.S., noted.

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The use of steroids is also linked to worsening diabetes among patients. Dr. Arvinder Singh Soin, chairman of the Institute of Liver Transplantation and Regenerative Medicine, called this a “vicious triangle” in a tweet. “Worse the diabetes (higher the blood sugar), more severe the Covid, and more the requirement for steroids. More the steroids, the worse the diabetes becomes,” Dr. Soin explained.

On Saturday, Dr. Randeep Gulerai also highlighted the abundant use of steroids as a primary reason for rising cases of mucormycosis across states. Overuse of the drugs can result in lowered immunity and raise blood sugar levels, leaving patients with uncontrolled diabetes and particularly vulnerable to fungal infections like mucormycosis. Elderly patients, those who have a history of high dose and long duration steroid therapy, and those who have recently recovered from Covid infection are at higher risk of getting infected with Covid-associated mucormycosis.

“The infection typically begins to hit the body two to three weeks into the steroid therapy, and we might see the case numbers jump in the coming weeks.” Manish Munjal, a surgeon at Sir Ganga Ram Hospital, told National Geographic. The fungal infection is hard to detect and has a 50% mortality rate if left untreated.

The Ministry of Health & Family Welfare also noted these caveats in its clinical guidelines regarding anti-inflammatory therapy — advocating for its use only in moderate and severe cases, when the patient is either in the ward or in the ICU and the oxygen level is dropping. This is also evident in a Covid19 case management protocol issued by the Tamil Nadu government, which advises the use of steroids like dexamethasone and methylprednisolone only if oxygen levels fall and restricts steroid use to seven days.

Lancelot Pinto, a pulmonologist at Mumbai’s P.D. Hinduja Hospital and Medical Research Center, spoke to National Geographic about the lack of scientific basis in recommending steroid therapy. “We’ve seen people go crazy with steroid prescriptions… There’s a misperception among doctors that more severe the [Covid19] case, higher the dose of steroids needed, which isn’t supported by any trial so far.”

An overwhelmed health system and a dangerously transmissible Covid variant has skyrocketed the popularity of steroid therapy, as doctors resort to different modulations when low doses of steroid or other treatments are not working. While steroids may help with short-term difficulties — like fever, nausea, and shortness of breath — they could potentially make the patient more susceptible to other fatal conditions because of a weakened immune system.

“We can do things in our control: Use steroids only when necessary, at the right time, for the right duration,” Vincent Rajkumar notes in a tweet. “This is truly a double edge sword that when used without care can cause tremendous harm.”