Q. I heard that steroids are being studied in Covid-19 persons. Is there any promise in this treatment or is it similar to previous trials like the hydroxychloroquine that proved to be more hype than substance?
A. Covid-19 has now affected millions of people worldwide; There have been over 100,000 thousand Canadians and tens of thousands of Ontarians with confirmed cases as of mid-July. We are also very connected to people throughout the world so it is not at all unusual to know of someone that has been affected by this virus.
According to medicalnewstoday.com, 80 per cent of people that do contract Covid-19 will be asymptomatic (showing no symptoms) or have mild symptoms that will resolve in a matter of days to weeks.
Nearly 14% will develop a severe case and develop shortness of breath thus requiring hospitalization. Among this group, 75% of them will show signs of bilateral pneumonia (a fancy term to describe pneumonia in both of your lungs). Inflammation occurs in the respiratory system causing the lungs to fill with pus or fluid and making our usual gas exchange (the intake of oxygen from our environment and the elimination of carbon dioxide from our body) less efficient all while increasing the physical effort required by our body to just breathe. This is followed by a fibrosis (scarring) stage. In the lungs, the tissues become damaged and possibly scarred making it even more difficult for your lungs to effectively work. It is during this inflammation stage that the use of steroids, namely dexamethasone, may come into play.
Researchers in England have studied dexamethasone, a long known and common corticosteroid, and have shown that its use looks like it can lead to a reduction of deaths by about 1/3 of the severely ill patients that were hospitalized. More specifically, it helped 35% of those who required ventilators and 20% of those requiring supplemental oxygen only. However, dexamethasone does not seem to give any advantage for people affected with milder cases of COVID-19 induced pneumonia. Dexamethasone may also be of use in patients with other complications resulting from a COVID-19 infection.
In a review published in the Canadian Medical Association Journal (CMAJ), the use of steroids such as dexamethasone appears to reduce mortality in Covid-19 patients with Acute Respiratory Distress Syndrome (ARDS), a term many of us became familiar with during the SARS epidemic of 2003. ARDS is the most severe form of an acute (i.e. recently occurring) lung injury most commonly caused by pneumonia but can be instigated by other causes as well. In this study the evidence appears to be inconclusive as to whether dexamethasone benefitted patients that did not suffer from ARDS.
Those sorts of “wishy-washy” results can be frustrating for both patients and their doctors but we must keep in mind that this is a novel coronavirus and thus the information we learn is ever changing, even many months in.
Western medicine has used corticosteroids for many decades for a variety of purposes. Corticosteroids are very effective at reducing inflammation in the body but they do have some negative effects as well. It can be a little harsh on the belly so it is advised to have it after a meal to protect the stomach. It is also known to negatively affect sleep so people are encouraged to take it as early in the day as possible to reduce the potential insomnia.
There are numerous other side effects but due to the short course of treatment, usually the benefits outweigh the risks. Other side effects that are routinely associated with long-term use of corticosteroids are not typically seen with the duration of treatment used for COVID-19. However, using dexamethasone is not a “no-brainer” and should be reserved for only those who are the “most sick”. Even short courses of it, or its sister drug prednisone, have been associated rarely with extremely negative health outcomes such as sepsis, a gastrointestinal bleed (i.e. an internal bleed originating from your stomach or intestines) or heart failure.
To answer your question, there seems to be some promise in this treatment for those that are ill enough to require mechanical ventilation or supplemental oxygen but not for those patients that do not. The dose of dexamethasone that was studied was 6mg daily, given either by mouth (orally) or by intravenous injection. The treatment should continue for 10 days unless discharged from the hospital prior to that.
This all seems promising, however dexamethasone happens to be one of the many medications that is in short supply worldwide and thus not available from many wholesalers meaning that there is a small chance it will not be available for those who need it most.
For more information on this or any other topic, contact your pharmacist.