Medical and Legal Considerations for the Use of Corticosteroids for Asthma Patients During the COVID-19 Crisis

Due to limited current information, researchers do not know with certainty whether people with asthma are at an increased risk for becoming infected with SARS-CoV-2, the coronavirus that causes COVID-19. This uncertainty creates a number of medical questions and consequently, raises various potential legal issues for both treating physicians and product manufacturers, whose products may be used to treat those patients.

The Current Research on Asthma Patients and COVID-19

Data is conflicting as to the susceptibility of people with asthma to contract COVID-19, but asthmatics who use steroids may be at higher risk.

Corticosteroids, a class of anti-inflammatory drugs, are often used to treat a number of different diseases (asthma, rheumatoid arthritis, and allergies). Reports have suggested that people who frequently use inhaled corticosteroids to control asthma may be more susceptible to serious infections, like pneumonia, because these medications can weaken a person’s immune system. (Qian et al., 2016) Therefore, when prescribing medications to treat or control asthma, physicians should consider the possibility that regular use of corticosteroids might reduce a person’s ability to fight off the SARS-CoV-2 infection, the coronavirus that causes COVID-19.

COVID-19 may be more severe in asthmatics who are infected with the new coronavirus.

In people with asthma, respiratory tract viral infections like influenza or pneumonia, may cause inflammation, which can lead to narrowing of the airways and exacerbation of asthma symptoms and attacks. The Centers for Disease Control (CDC, 2020) has warned that people with moderate to severe asthma who become sick with COVID-19 are at an increased risk for severe cases of COVID-19 since the disease can affect the respiratory tract, triggering an asthma attack and potentially causing pneumonia or acute respiratory disease.

Current recommendations for people with asthma.

Asthmatics are being advised to continue taking medications as prescribed to control their asthma, along with other restrictions to avoid potential asthmatic triggers and infections. People with asthma are also being advised to keep an emergency 30-day supply of prescription medications, including oral medications, asthma inhalers, and non-prescription supplies on hand. However, some of these same medications used to treat asthma are now also in high demand to treat COVID-19 patients.

A shortage of albuterol inhalers may dictate other treatments for people with asthma.

“Rescue” inhalers are quick-acting bronchodilators used to relieve asthma symptoms and attacks. Bronchodilators relax muscles in the lungs, which then causes widening of the airways and allows increased flow of air to the lungs. The CDC and WHO have both advised physicians not to prescribe corticosteroids to COVID-19 patients unless indicated for other reasons. Thus, non-steroidal bronchodilators, like albuterol, are being prescribed more for COVID-19 patients which is creating a higher demand for the therapy. A shortage of albuterol, which is currently used as a “rescue” inhaler for asthma, is being reported. Therefore, physicians may need to prescribe treatments other than albuterol for asthmatic patients, including the possibility of prescribing more corticosteroids.

Does prescribing corticosteroids create liability for physicians and/or manufacturers if the patient subsequently has a severe case of COVID-19?

Given the data and warnings that the use of treatments that contain steroids in asthmatic patients increase the risk of infection and the possibility of infection from COVID-19, the resulting treatment decisions can create legal issues for physicians who prescribe a corticosteroid as an alternative to albuterol to treat patients with asthma and for the companies who design and manufacture those products.

Legal Issues for Prescribing Physicians

Typically, physicians are afforded certain protections, such as Good Samaritan laws, so long as they are using reasonable judgment while following the standard of care and not acting negligently or recklessly. However, it is less clear at this time whether physicians will be afforded the same protections in a pandemic unless clear medical guidelines are implemented in part with executive orders instituting a state of emergency to standardize triage of patients and the medical rationing of treatment. (Cohen 2020) If a physician prescribes these medications while adhering to guidelines for medical rationing, it seems less likely that a lawsuit could be successfully brought against a physician or facility that prescribes a corticosteroid to an asthmatic who subsequently has a severe case of COVID-19 in the interest of reserving albuterol to treat other COVID-19 patients without prior asthma or respiratory disease.

Legal Issues for Product Manufacturers

There is more question though for manufacturer liability if a corticosteroid is prescribed to an asthmatic who then subsequently has a severe case of COVID-19. If the use of a prescription drug could place the user at a higher risk of a respiratory infection or weaken their immune system, the manufacturer has the duty to warn users of their drug of this risk if this was a foreseeable harm. With corticosteroids, manufacturers warn, or should be warning, users and prescribers of the possibility of weakened immune systems and an increased risk of infections. However, it is unclear if a manufacturer has a heightened duty to warn that their product puts users at a higher risk of a specific virus, here COVID-19, that has caused a pandemic, although proactively warning and educating users and prescribers of the heightened risk may help assuage some risks of a lawsuit.

https://www.health.com/condition/infectious-diseases/coronavirus/people-with-asthma-have-higher-risk-coronavirus (Gillespie, 2020) (Main article)

https://onlinelibrary.wiley.com/doi/epdf/10.1111/all.14289 (Dong et al., 2020) (Low prevalence of asthma in COVID-19 patients)

https://onlinelibrary.wiley.com/doi/epdf/10.1111/all.14238 (Zhang et al., 2020) (Investigation in Wuhan, China)

https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.13295 (Qian et al., 2016) (Inhaled corticosteroids and pneumonia)

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/asthma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fasthma.html (CDC, 2020) (Severity of COVID-19)

https://jamanetwork.com/journals/jama/fullarticle/2764239 (Cohen, 2020) (Liability)