WHO Backs Steroids for COVID-19: How Does Dexamethasone Help?
While the study on Dexamethasone is interesting, experts say its not a magic bullet.
(An analysis conducted by The World Health Organisation across hospitals in eight countries has found that inexpensive, widely available steroids improve the odds of very sick COVID-19 patients surviving the illness. The findings confirm the results of an earlier trial on dexamethasone. FIT is republishing this explainer in that light.)
The rise and demise of hydroxychloroquine, an anti-malaria drug once touted as the 'wonder drug' to treat COVID-19, has made the world wary of anything that claims to be 'exceptional,' 'magic bullet,' or 'definitive' treatment.
When preliminary results from a recent study touted an old, cheap, anti-inflammatory drug dexamethasone as the '1st treatment for COVID-19 to reduce mortality,' there was cautious hope, accompanied by a healthy dose of skepticism.
What has bugged researchers, doctors and scientists across the world is the treatment claim by 'press release,' a trend more often than not seen through the pandemic.
While they wait for the full trail data to be published, these are the broader findings: the steroid drug can reduce mortality by upto a 3rd among ICU patients on ventilators and by a 5th among oxygen supported patients.
But what is dexamethasone, what role does it play in treatment for COVID patients, and is it being used in India? Let's answer these questions one-by-one:
What is Dexemathasone?
Dexamethasone is cheap, costs less than 30 paise, a strip of 10 comes at Rs 3, and some 20 companies make the drug in India.
Dexamethasone falls under a class of drugs known as corticosteroids and is used to treat a range of inflammatory conditions including arthritis and other rheumatic problems, swelling in the brain, allergies, asthma and other breathing difficulties. Even eye and dental inflammation is often treated by the steroid.
What do we know about the study so far?
In March 2020, the UK launched its RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial to test if a range of potential treatments and repurposed drugs for COVID-19, actually worked. These were randomised clinical trials and included the low-dose dexamethasone. Over 11,500 patients have been enrolled from over 175 NHS hospitals in the UK as part of the RECOVERY trials.
As part of the dexamethasone study, 2104 patients received dexamethasone 6 mg once per day (oral or intravenous) for ten days and 4321 patients received usual care alone.
Dexamethasone reduced deaths by one-third in patients on ventilators and by one fifth in patients receiving oxygen only. No benefit was seen in those who required no respiratory support.
The release claims that 1 death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.
Study authors are now saying the results are significant enough to make dexamethasone 'standard of care' for these patients.
‘Dexamethasone is the first drug to be shown to improve survival in COVID-19. 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.’ Peter Horby, Professor of Emerging Infectious Diseases in the Nuffield Department of Medicine, University of Oxford, is one of the Chief Investigators for the trial.
What's important to note here is the treatment worked only for patients under respiratory distress, not for those with mild symptoms.
Speaking to FIT, Dr Sumit Ray, critical care specialist in Delhi who looks after COVID patients, had this to say:
"The reason why the NHS decided to use dexamethasone for its RECOVERY trial was because there was already some evidence that some steroids work in COVID patients in clinical settings. Here in India, we were already using steroids, higher dosage than this, in some patients. It's important to note that this is not a magic bullet. Not all patients needs to take dexamethasone and like all steroids, it makes you prone to secondary infections."
How Does it Help COVID Patients?
A patient with severe COVID-19 often experiences what is known as a cytokine storm.
This is how it happens: When a virus invades the lungs, the body's defence mechanism, the immune system gets into action to control it. The body's innate immunity kicks in, producing more infection-fighting white blood cells. Sometimes, the immune goes into overdrive by an excessive and exorbitant amount of cytokine production, turning the ‘localised’ inflammation into hyper-inflammation, impacting not just the infected areas, but the rest of the body as well.
These patients are often given anti-inflammatory drugs to reduce pressure on the the lungs. The UK researchers used dexamethasone as the steroid of choice.
Interestingly, anti-inflammatory drugs are being used as part of treatment protocol in clinical settings already.
"In many patients there is an increase in the release of cytokines in reaction to the infection. To modulate this response, at a lower dosage, steroids are used. In RECOVERY TRAILS the dosage was very less, in other studies for Acute Respiratory Distress Syndrome (ARDS), the dosage used is higher. We expected this kind of response to the study based on the initial feedback we got from our colleagues in the UK and US who had treated COVID patients before us. Here in India, almost all of us are using steroids for a certain subset of patients in clinical settings," says Dr Ray.
Dr Ray also points that since the drug is cheap, out of patent, done by NHS, what's interesting about this specific study is the lack of conflict of interest that many recent studies have had that have been backed by big pharma companies.
Can All COVID Patients be Given Dexamethasone?
As already established, the drug works in specific clinical settings on patients with breathing difficulties who are either on ventilators or need oxygen therapy.
It has no benefit whatsoever on patients with mild symptoms.
Currently, in India Indian Council of Medical Research has NOT approved the drug as part of treatment protocol. An announcement is awaited.
There are complications associated with the drug. For one, in order to reduce the inflammation, the steroid will suppress the immune system. If you have other infections, co morbid conditions, the doctors will have to evaluate if the drug will do more harm than good.
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