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Comment & Response
March 21, 2022

Inhaled Ciclesonide for Patients With Asthma or Chronic Obstructive Pulmonary Disease and COVID-19

Author Affiliations
  • 1Division of Pulmonary, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
  • 2Cardinal Tien Hospital and School of Medicine, College of Medicine, Department of Internal Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
  • 3Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan
JAMA Intern Med. 2022;182(5):571-572. doi:10.1001/jamainternmed.2022.0207

To the Editor We read with great interest the recent article by Dr Clemency and colleagues1 who investigated the efficacy of inhaled ciclesonide for patients with symptomatic COVID-19 in an outpatient setting. This randomized clinical trial observed no significant differences between the ciclesonide intervention and placebo arms regarding time to alleviation of all COVID-19−related symptoms nor resolution of all symptoms by day 30. In contrast, the ciclesonide treatment arm had fewer COVID-19-related emergency department visits and hospitalization than the control. However, we have 2 substantial concerns with these findings.

First, the baseline characteristics of the participants in the treatment arm differed from those of the control arm. More patients with asthma were in the treatment vs the placebo arm (9.1% vs 3.9%; P = .04).1 As we know, inhaled corticosteroids are a key treatment for patients with asthma because it helps to reduce the risk of asthma-related exacerbation and death, even in patients with mild asthma.2 Thus, inhaled corticosteroids may help prevent an asthma flare-up associated with COVID-19. In addition, we do not think it is easy to determine whether the symptoms, such as cough and dyspnea, were related to COVID-19 or to asthma flare-up. To avoid the possible confounding effect of asthma, a subgroup analysis is needed.

Second, use of inhaled corticosteroids is important for patients with chronic obstructive pulmonary disease (COPD), especially for patients at risk of exacerbation.3 However, Dr Clemency and colleagues1 did not mention the prevalence of COPD among the participants nor the prevalence of smoking status or other chronic lung diseases.

We think these data should be added. Because inhaled corticosteroids can affect the outcomes of patients with asthma, COPD, and other chronic lung diseases, the possible confounding effects of these diseases should be minimized in a study investigating the efficacy of inhaled corticosteroids.

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Article Information

Corresponding Author: Chih-Cheng Lai, MD, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan City 710, Taiwan (dtmed141@gmail.com).

Published Online: March 21, 2022. doi:10.1001/jamainternmed.2022.0207

Conflict of Interest Disclosures: None reported.

Clemency  BM, Varughese  R, Gonzalez-Rojas  Y,  et al.  Efficacy of inhaled ciclesonide for outpatient treatment of adolescents and adults with symptomatic COVID-19: a randomized clinical trial.   JAMA Intern Med. 2022;182(1):42-49. doi:10.1001/jamainternmed.2021.6759PubMedGoogle ScholarCrossref
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2021. Accessed February 14, 2022. https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. 2022. Accessed February 14, 2022. https://goldcopd.org/wp-content/uploads/2021/11/GOLD-REPORT-2022-v1.0-12Nov2021_WMV.pdf