Patient-Oriented Evidence That Matters

Inhaled Budesonide Reduces the Risk of Emergency Department Evaluation or Hospitalization in Early COVID-19


Am Fam Physician. 2021 Aug ;104(2):207-208.

Clinical Question

Does inhaled budesonide (Pulmicort) safely reduce the likelihood of requiring emergency department consultation or hospitalization in patients with new-onset, symptomatic COVID-19?

Bottom Line

Inhaled budesonide, 800 mcg twice daily, significantly reduces the likelihood that patients with early COVID-19 will require emergency department evaluation or hospitalization (number needed to treat [NNT] = 7 to 8). This is a widely available, relatively inexpensive drug with the potential for great benefit. There are seven other trials underway looking at inhaled budesonide or ciclesonide (Alvesco); the results are urgently awaited. (Level of Evidence = 1b−)


From previous randomized trials, we know that oral corticosteroids such as methylprednisolone are only helpful in more severely ill patients with COVID-19, and there was a trend toward worse outcomes in those with mild disease, perhaps by suppressing immune function systemically. Observational studies have shown an association between inhaled corticosteroids and better outcomes in patients with mild disease.

The researchers identified adults with less than seven days of cough, and either fever or anosmia or both (N = 146). They randomized the patients to receive budesonide using 400-mcg actuations, with two actuations twice daily, or usual care. A nurse did a swab for SARS-CoV-2, which was positive for 94% of patients. Groups were balanced at randomization. Four patients withdrew consent before receiving the allocated intervention, one in each group needed urgent care before they could be swabbed, and one withdrew because they found the inhaler too burdensome, leaving a per-protocol population of 139 patients. Patients in the budesonide group were told to stop using the inhaler when they had recovered (median = seven days), and all patients were followed up for 28 days.

It does not appear that outcomes were assessed in a masked manner, and the study was stopped early because of the large benefit. In

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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