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covid-19: cheap steroid helps reduce deaths in critically ill — not mild illness
low doses of dexamethasone reduced deaths in ventilated patients — but it won't prevent covid-19 or even help those who are mildly ill.
jun 17 2020
4 minute read
in a large trial, dexamethasone was shown to improve survival for severely ill covid-19 patients who required ventilation. however, the study has not yet been published or held up to scientific scrutiny.
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- 6 mg of dexamethasone can help reduce death in people in the icu who have had symptoms for more than seven days
- it does not help people who are not on supplemental oxygen
- it doesn’t prevent you from getting covid-19
- it has no benefit for people in their first week of illness
- interestingly, it does not have a clear benefit for people over 70 years old
this story was originally published on june 17 and has been updated on june 23 to include the full study.
a new drug trial has found that low doses of a cheap steroid drug may be able to improve the odds of survival in the sickest covid-19 patients.
it’s the first therapy that has been found to reduce deaths by one-third in severely ill covid-19 patients who required ventilation. it also reduced deaths by one-fifth in patients who required oxygen only.
the trial did not see any benefit in patients who did not need help breathing.
dexamethasone is a steroid drug most commonly used to treat conditions like inflammation (swelling), severe allergies, adrenal problems, arthritis, asthma, blood or bone marrow problems, kidney problems, skin conditions, and flare-ups of multiple sclerosis.
it should only be taken as exactly described by your doctor.
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the trial comes from the u.k.’s recovery trial (randomised evaluation of covid-19 therapy). the press release was first published alone on june 16 and thefull study preprint (has not yet been peer-reviewed) was published online on june 22.
it confirms that dexamethasone doesn’t help mild illness from covid-19. it won’t prevent you from getting covid, and there was no benefit shown for people taking it in their first week of illness.
interestingly, it did not help those over 70 years old and it does not prevent hospitalizations.
it does appear to help prevent death in those under 70 years old in the icu who are on oxygen support and have had symptoms for more than seven days.
the trial included 2,104 patients who received 6 mg dexamethasone once a day for 10 days (either taken orally or through iv injection). the comparison group were 4,321 patients that received usual care.
based on these results, they found one life could be saved for every eight patients on ventilators. for patients on oxygen alone, one life could be saved for every 25 treated.
the vast majority of covid-19 patients recover without being admitted to the hospital , and of those admitted, only a small minority require oxygen or mechanical ventilation. it’s this small subset of the most severely ill patients that dexamethasone appears to help.
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patients who require oxygen or ventilation generally have pneumonia and develop shortness of breath, respiratory failure, and acute respiratory distress syndrome (ards) — when patients are unable to breathe because there is inflammation and fluid filling up the air sacs in their lungs. once ards develops, the mortality rate goes up significantly and the need for critical care and life support is increased.
the world health organization (who) welcomed the “scientific breakthrough” for severe covid-19 patients and announced on wednesday it would be coordinating a meta-analysis to pool data from several clinical trials and increase overall understanding of dexamethasone as an intervention. the who also announced it would be updating clinical guidelines and how and when dexamethasone should be used.
this study has come as a surprise to much of the scientific community. a lancet study published in the earlier days of covid-19 had in fact found corticosteroid, like dexamethasone, may cause serious harm and complications to rsv, influenza, sars, and mers patients .
as with very discovery, it opens a whole field of new questions. what does this mean for other causes of ards? we now know that there is a group of ards patients who do better with dex (i.e. those with covid). this probably applies to other ards subgroups. how do we find them?
— kenneth baillie (@kennethbaillie) june 16, 2020
dexamethasone has huge life-saving potential being the first drug shown to reduce mortality. but it helps those who have the most severe cases from becoming worse and critically ill. a vaccine is still needed to prevent spread of the virus.
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even with the full study now published, there are still many unanswered questions. dr. eric meyerowitz, an infectious diseases fellow, shared his interpretations on twitter. some concerns include
— eric meyerowitz, md (@ericmeyerowitz) june 23, 2020
when dr. nahid bhadelia, an infectious diseases physician and associate professor at the boston university school of medicine, urged caution when the press release was first published and need more data before introducing dexamethasone into current practice.
but i think we physicians want to see the data to figure out what was different about this study population & concurrent medical treatment (i.e. empiric antibiotic use?) that resulted in different outcomes. the data will also help us better select patients would benefit most.
— dr. nahid bhadelia (@bhadeliamd) june 16, 2020
“the reason steroids haven’t been used widely to date is because results from prior cohorts have been mixed (including increased mortality) & there has been a concern steroids lead to secondary bacterial infections & increase viral load,” she writes on twitter.
dr. bhadelia writes that while this is good news, results from using steroids in ards are mixed and “benefit of low-dose steroids also seems to be limited to certain etiologies and patient subgroups.”
surgeon dr. atul gawande has also urged caution and needs to be held up to further scrutiny.
it will be great news if dexamethasone, a cheap steroid, really does cut deaths by 1/3 in ventilated patients with covid19, but after all the retractions and walk backs, it is unacceptable to tout study results by press release without releasing the paper. https://t.co/zp5gvmucw3
— atul gawande (@atul_gawande) june 16, 2020
“dexamethasone is the first drug to be shown to improve survival in covid-19,” said peter horby, professor of emerging infectious diseases in the nuffield department of medicine, university of oxford, and one of the chief investigators for the trial.
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“this is an extremely welcome result. the survival benefit is clear and large in those patients who are sick enough to require oxygen treatment, so dexamethasone should now become standard of care in these patients. dexamethasone is inexpensive, on the shelf, and can be used immediately to save lives worldwide.”
the recovery trial is a large, randomized controlled trial of possible treatments for patients admitted to hospital with covid-19. more than 11,500 patients have been randomized to the following treatment arms, or no additional treatment:
- lopinavir-ritonavir (commonly used to treat hiv)
- low-dose dexamethasone (a type of steroid, which typically used to reduce inflammation)
- hydroxychloroquine (which has now been stopped due to lack of efficacy)
- azithromycin (a commonly used antibiotic)
- tocilizumab (an anti-inflammatory treatment given by injection)
- convalescent plasma (collected from donors who have recovered from covid-19 and contains antibodies against the sars-cov-2 virus).
dduong@postmedia.com | @dianaduo
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