Nasal Corticosteroids Increases SARS-CoV-2 infection Risk in Adults

A recent study showed that nasal corticosteroids increase the risk of SARS-CoV-2 infection in adults but not children.¹

“Similar, albeit less consistent, age-dependent findings were observed for inhaled corticosteroid use,” wrote investigators, led by Christian Rosas-Salazar, MD, MPH, associate professor of pediatrics, allergy/immunology, and pulmonary medicine at Vanderbilt University Medical Center in Nashville.¹

The upper respiratory tract functions as the main entry point for SARS-CoV-2 infection. From the time between airborne exposure to SARS-CoV-2, many factors, including differences in cell receptors, intracellular signaling, and host defense pathways, can determine the effective entry of SARS-CoV-2 into the URT cells and the start of the infection.² However, nasal or inhaled corticosteroids may impact the URT cell entry process.

Investigators hypothesized that the use of topical airway corticosteroids alters the risk of SARS-CoV-2 infection.¹ In the prospective, multicenter Human Epidemiology and RespOnse to SARS-CoV-2 (HEROS) trial, the team aimed to assess whether nasal or inhaled corticosteroid use increased the risk of SARS-CoV-2 infection in adults and children with allergic rhinitis or asthma. They examined the association of nasal or inhaled corticosteroids at baseline with the first SARS-CoV-2 positive quantitative PCR testing.

The team conducted a prospective, multicenter, SARS-CoV-2 surveillance study of 1113 households with children under < 21 years, totaling 2211 participants. Households included participated in 20 National Institutes of Health-funded cohorts focused on atopic diseases in 12 cities between May 2020 and February 2021. The study only included participants with a self-reported prior diagnosis of allergic rhinitis (46%) or asthma (28%).

The sample, including adults (47%) and children (53%), had 1285 females (58%) and 1220 (57%) who reported as non-Hispanic White. More than 100 participants (n = 145; 7%) developed a SARS-CoV-2 infection during the study.

Primary adult caregivers completed questionnaires at baseline and the end-of-study on sociodemographic factors, medical history, and current medication use. Every 2 weeks, the team collected nasal swabs and asked about COVID-19-related symptoms. Participants completed weekly symptom questionnaires.

Participants aged > 2 years also had blood allergen-specific IgE testing, self or caregiver-collected with the Tasso home collection device. They had specific IgE testing to 112 aeroallergens and foods from 48 sources.

The analysis found that nasal and inhaled corticosteroids were individually associated with a greater risk of SARS-CoV-2 infection among adults (adjusted hazard ratio [aHR], 1.88; 95% confidence interval [CI], 1.14 – 3.12; P = .01 and aHR, 2.15; 95% CI, 1.003 – 4.63; P = .049, respectively).¹

“Some of our findings suggest that the risk of SARS-CoV-2 infection could also be increased in adults who use [inhaled corticosteroid],” investigators wrote.¹ “However, we found a relationship between the number of asthma controllers (a marker of the underlying asthma severity) and the risk of SARS-CoV-2 infection in adults. These findings suggest that confounding could have biased the association between [inhaled corticosteroid] use and the risk of SARS-CoV-2 in adults, which prevents us from establishing firm conclusions about this relationship.”

Sensitivity analyses also showed the link between nasal corticosteroid use with the risk of SARS-CoV-2 infection in adults. Nasal and inhaled corticosteroid use was not linked to an increased SARS-CoV-2 risk in children.

“Our findings are important as topical airway corticosteroids are among the most commonly used medications for the management of pediatric and adult allergic and respiratory disorders, and understanding their safety profile could aid COVID-19 public health measures,” investigators concluded.¹ “These findings, while informative, are constrained by the observational study design and do not imply causation.”

References

1. Rosas-Salazar C, Gebretsadik T, Seibold MA, Moore CM, Arbes SJ, Bacharier LB, Brunwasser SM, Camargo Jr. CA, Dupont WD, Furuta GT, Gruchalla RS, Gupta RS, Jackson DJ, Johnson CC, Kattan M, Khurana Hershey GK, Liu AH, O’Connor GT, Phipatanakul W, Ramratnam SK, Rothenberg ME, Sajuthi SP, Sanders J, Seroogy CM, Snyder BM, Stelzig L, Teach SJ, Zoratti EM, Togias A, Fulkerson PC, Hartert TV, on behalf of the HEROS Study Group, Impact of Nasal and Inhaled Corticosteroids on SARS-CoV-2 Infection Susceptibility, The Journal of Allergy and Clinical Immunology (2025), doi: https://doi.org/10.1016/j.jaci.2025.07.006.

2. Jackson CB, Farzan M, Chen B, Choe H. Mechanisms of SARS-CoV-2 entry into cells. Nat Rev Mol Cell Biol. 2022;23(1):3-20. doi:10.1038/s41580-021-00418-x