People still ask if an asthma inhaler could take the sting out of COVID. The short answer: budesonide may shorten symptoms by a day or two when started early in some higher‑risk adults, but it hasn’t shown a reliable drop in hospitalisations or deaths. It’s not a substitute for antivirals, and most guidelines don’t recommend starting it just for COVID unless a clinician sees a specific reason. If you already use it for asthma or COPD, keep taking it.
- TL;DR: Early trials showed faster recovery with inhaled budesonide, but no consistent reduction in severe outcomes.
- 2025 view: Prioritise antivirals (e.g., nirmatrelvir/ritonavir) for at‑risk outpatients. Budesonide is optional at best and not routine.
- Safety: Common issues are hoarseness and oral thrush; rinse after use. Watch for interactions with ritonavir (Paxlovid).
- Dose studied: 800 micrograms twice daily via dry‑powder inhaler for up to 14 days (if prescribed).
- Keep taking your regular inhaled steroids for asthma/COPD-don’t stop because of COVID.
What budesonide is and why it was considered for COVID
Budesonide is a long‑standing inhaled corticosteroid (ICS) most people know from asthma and COPD treatment. It tames airway inflammation and, at inhaled doses, stays mostly in the lungs with relatively low systemic exposure.
So why did it get attention in COVID? Two reasons. First, steroids calm inflammation. In COVID, the immune response can become overactive and inflame the airways, especially in the second week. Second, lab work early in the pandemic hinted that inhaled steroids could reduce the expression of ACE2 and TMPRSS2-the proteins the virus uses to enter cells-which raised the idea they might slow viral replication in the airways.
That biological plausibility led to early clinical trials in the community. People wanted something that was cheap, widely available, and familiar. In Australia (I’m in Sydney), many GPs had patients already on budesonide for asthma; the question was whether starting it in newly infected, higher‑risk adults could meaningfully change the course of illness.
The evidence: what trials show (and don’t)
Two key randomised trials shaped the conversation.
- STOIC trial (Ramakrishnan et al., 2021): A small UK study in adults with early, mild COVID. Budesonide users had fewer urgent care visits and recovered faster. This was encouraging but small and pre‑vaccine.
- PRINCIPLE trial (2021, University of Oxford): A large, open‑label platform trial in older adults or those with risk factors. Budesonide shortened time to recovery by about 2-3 days when started within 14 days of symptoms. It did not show a clear reduction in hospitalisation or death.
As vaccination rose and variants changed, bigger questions emerged: Does this benefit hold for vaccinated, Omicron‑era patients? Systematic reviews through 2023-2024 (including Cochrane analyses of inhaled corticosteroids for ambulatory COVID) found:
- Moderate evidence that ICS (largely budesonide) shorten time to recovery by roughly 1-3 days in some higher‑risk outpatients.
- Low or very low certainty that ICS reduce hospitalisation or mortality-most data suggest little to no effect on these outcomes.
- Open‑label designs can bias symptom‑based endpoints (people who know they’re on treatment may report feeling better sooner). That tempers confidence in the size of the benefit.
Hospital‑based steroid data are a different story. Dexamethasone reduces deaths in patients needing oxygen or ventilation (RECOVERY trial, 2020). But that’s a systemic steroid in moderate-severe disease, not an inhaler for early, mild illness. You can’t assume the same effect.
Bottom line from the trials: budesonide can speed up symptom relief for some, but it hasn’t proven to keep people out of hospital in a reliable way, especially in a vaccinated population.
Where it fits in 2025 care: who might consider it, who shouldn’t
Most major guidelines in 2024-2025-NIH COVID‑19 Treatment Guidelines (US), IDSA (US), WHO-do not recommend starting inhaled corticosteroids for the treatment of COVID‑19 in outpatients outside a clinical trial. They consistently say: continue ICS if you use them for asthma or COPD. The Australian National COVID‑19 Clinical Evidence Taskforce has moved the same direction: don’t use inhaled steroids routinely for COVID; prioritise proven antivirals in at‑risk adults.
So, when could budesonide still be considered?
- You’re an outpatient at higher risk of progression (older age, chronic conditions) within the first 5-7 days of symptoms, and your clinician judges a likely symptom‑relief benefit, especially if antivirals are not available, contraindicated, or declined.
- You have persistent post‑infectious cough after COVID. Some cough guidelines allow a short trial of inhaled steroids for post‑viral cough; individual response varies.
When should you not start budesonide just for COVID?
- If you’re low risk and recovering well-there’s little upside beyond maybe a day faster recovery.
- If you’re eligible for antivirals-don’t delay starting them while you chase an inhaler. Antivirals have the clearest impact on preventing severe disease when started early.
- If a strong CYP3A inhibitor (like ritonavir in Paxlovid) poses a meaningful interaction risk your clinician is concerned about. More on this below.
Special note if you already use an ICS: Keep taking it for your asthma or COPD. Stopping controller therapy can trigger flare‑ups. Every major guideline agrees on this.
How to use it safely if your doctor recommends it
If your clinician recommends a trial specifically for acute COVID, they’ll usually mirror the dosing used in research:
- Dose studied: 800 micrograms twice daily via dry‑powder inhaler (e.g., Turbuhaler/Flexhaler) for up to 14 days, or until you feel well for a couple of days.
- Start as early as possible in the illness. The signal for benefit (symptom shortening) was strongest when started within the first week.
Step‑by‑step inhaler technique (dry‑powder device):
- Load the dose per your device (twist/click as instructed).
- Exhale away from the inhaler-don’t blow into it.
- Seal your lips on the mouthpiece, inhale quickly and deeply.
- Hold your breath for 10 seconds, then exhale slowly.
- Repeat if prescribed more than one inhalation per dose.
- Rinse your mouth and gargle; spit out the water. This cuts the risk of thrush and hoarseness.
Metered‑dose inhaler (if that’s your device):
- Use a spacer if you have one-it helps lung delivery.
- Shake, exhale gently, seal lips, press and inhale slowly.
- Hold breath 10 seconds, then exhale.
- Rinse and spit after the final puff.
Nebulised budesonide isn’t used for treating COVID itself and can aerosolise virus in shared spaces. If you use a nebuliser for another condition and you’re isolating at home, do it in a well‑ventilated room away from others.
Side effects to watch for:
- Local: hoarseness, sore throat, oral thrush (white patches). Rinsing after each dose is the best prevention.
- Systemic (rare at inhaled doses): easy bruising, adrenal suppression, mood changes. These are uncommon, but the interaction below can raise the risk.
Key interaction-ritonavir (Paxlovid):
- Budesonide is broken down by CYP3A4. Ritonavir strongly blocks CYP3A4 and can raise steroid levels.
- With just 5 days of Paxlovid, the absolute risk of steroid side effects from a standard ICS dose is likely low, but case reports exist (more with fluticasone) of steroid excess and adrenal suppression when combined with ritonavir.
- Don’t stop your regular ICS without advice. If you’re starting Paxlovid, ask your GP/pharmacist whether to continue, adjust, or temporarily switch your inhaler. They’ll weigh your asthma control against the small, short‑term interaction risk.
Other interactions: Strong CYP3A inhibitors (e.g., certain antifungals like ketoconazole, some macrolides) can also raise steroid levels; the same caution applies.
Practical rules of thumb:
- Antivirals first for eligible patients; add‑ons like ICS should never delay day‑1 to day‑5 antiviral starts.
- If budesonide is used, use it early, use the studied dose, and stop when you’re better.
- Rinse and spit after each dose; this prevents most local side effects.
- Monitor your symptoms. If your breathing worsens, oxygen levels drop, or fever spikes after day 4-5, contact your clinician-don’t assume the inhaler will cover it.
Quick tools: decision guide, checklist, and mini‑FAQ
Simple decision guide (for conversations with your clinician):
- Are you at higher risk for severe COVID (age 65+, chronic diseases, immunocompromised, pregnancy)?
- Yes: Seek antivirals immediately if within 5 days of symptoms. Budesonide may be considered for symptom relief if there’s a good rationale and no red‑flag interactions.
- No: Rest, fluids, symptom control. Budesonide adds little for most low‑risk adults.
- Already on an ICS for asthma/COPD?
- Yes: Continue it. If starting Paxlovid, ask if any adjustments are needed.
- No: Don’t start an ICS without a clear plan from your clinician.
- Access issues or antiviral contraindications?
- If antivirals aren’t an option, a short course of budesonide for earlier symptom relief can be reasonable in some higher‑risk adults-this is a case‑by‑case call.
Checklist before starting budesonide for COVID (if advised):
- Timing: within 7 days of symptoms, ideally earlier.
- Dose: 800 mcg twice daily (dry‑powder) up to 14 days, or as directed.
- Technique: confirm device steps; use a spacer if it’s an MDI.
- Rinse and spit after each use.
- Drug interactions checked (especially ritonavir/Paxlovid).
- Plan for escalation: when to call, when to seek urgent care.
Examples (real‑world scenarios from a Sydney winter):
- Healthy 28‑year‑old, day 3 of mild symptoms, vaccinated: Focus on rest, fluids, paracetamol/ibuprofen as needed. Budesonide adds little.
- 68‑year‑old with diabetes, day 2: Start antivirals right away if eligible. If coughing is harsh and access to antivirals is delayed or contraindicated, your GP might consider a short budesonide trial for symptom relief.
- Asthma patient already on budesonide/formoterol: Keep your controller. If starting Paxlovid, check with the GP for any temporary adjustments; don’t stop abruptly.
- Persistent cough 6 weeks after COVID: A short ICS trial is sometimes used for post‑viral cough. It’s a test‑and‑see-stop if there’s no benefit.
Mini‑FAQ:
- Does budesonide prevent long COVID? There’s no solid evidence it prevents long COVID. Its role is mainly symptom relief in the acute phase for some patients.
- Can I use it “just in case” if I test positive? Not without a plan from your clinician. It won’t replace antivirals if you qualify for them.
- Is there any harm in trying? Mostly minor risks when used briefly and correctly. The main concern is drug interactions (ritonavir) and the risk of delaying better treatments.
- Is dexamethasone better than budesonide? Different use cases. Dexamethasone helps hospitalised patients needing oxygen. It’s not recommended for people with mild COVID at home.
- What about other inhaled steroids (fluticasone, ciclesonide)? Data are mixed and less convincing. Fluticasone has more interaction concern with ritonavir.
- Pregnant or breastfeeding? Talk to your obstetric provider. Budesonide has the most pregnancy safety data among ICS for asthma, but decisions for COVID should still be individualised.
Next steps / troubleshooting by persona:
- At‑risk adult on day 1-3: Book testing confirmed; contact your GP or hotline for antivirals. If you can’t get antivirals, discuss if a short budesonide course for symptom relief makes sense.
- Low‑risk adult: Manage symptoms at home. No need to add an ICS unless your GP sees a reason (e.g., asthma‑like wheeze).
- Asthma/COPD on maintenance ICS/LABA: Continue your preventer. Have your action plan handy. If you’re prescribed Paxlovid, ask about any temporary inhaler tweaks; keep a close eye on control.
- On Paxlovid already: Don’t start new steroids without checking interactions. If you develop red‑flag symptoms (worsening breathlessness, low oxygen, chest pain), seek urgent care.
- Regional/remote with limited access: Aim for antivirals via telehealth if eligible. If that’s not possible, a clinician‑guided budesonide plan may be reasonable for symptom control in higher‑risk patients.
Citations you can trust: PRINCIPLE trial (University of Oxford, 2021); STOIC trial (Ramakrishnan et al., 2021); NIH COVID‑19 Treatment Guidelines (updated through 2024); IDSA Guidelines (2024); WHO living guidelines (2024); National COVID‑19 Clinical Evidence Taskforce (Australia) updates 2024-2025; Cochrane Reviews on inhaled corticosteroids for ambulatory COVID (latest updates through 2023-2024). These sources align on a simple theme: budesonide can help some people feel better sooner, but antivirals are the backbone for preventing severe disease.
One last practical note from life here in Sydney: every winter wave looks a little different. What doesn’t change is the playbook-test early, call your GP early if you’re at risk, start antivirals promptly if you qualify, and use add‑ons like budesonide only when they add clear value. I still walk Rufus past packed pharmacies on Saturday mornings; the folks who fare best usually had a plan before they got sick.