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My thoughts on RECOVERY trial results (not data). First, here is the methodology & results.
-Large (11k) trial testing multiple treatment arms
-2104 randomised to dexamethasone 6mg/d for ten days and compared with 4321 patients randomised to usual care alone.
-Large (11k) trial testing multiple treatment arms
-2104 randomised to dexamethasone 6mg/d for ten days and compared with 4321 patients randomised to usual care alone.
Dexamethasone reduced deaths by 1/3 in ventilated patients (p=0.0003), 1/5 in other patients receiving oxygen only (p=0.0021), no benefit in patients who did not require oxygen (p=0.14).
It reduced the 28d mortality by 17% (P=0.0007) w greatest benefit in pts requiring vents.
It reduced the 28d mortality by 17% (P=0.0007) w greatest benefit in pts requiring vents.
Mechanistically, this make sense as this disease is a result of direct damage by viral & damage from out of control immune activation & inflammation. In severe disease, inflammation & clotting seem to lead to lung injury. Steroids suppress immune system. https://www.ncbi.nlm.nih.gov/research/coronavirus/publication/32427582
And other immune therapies are considered and being studied for covid19
https://www.ncbi.nlm.nih.gov/pubmed/32192578 .
Including those that block specific parts of immune response such as IL-6 and IL-1 pathways. https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/
https://www.ncbi.nlm.nih.gov/pubmed/32192578 .
Including those that block specific parts of immune response such as IL-6 and IL-1 pathways. https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/
The reason steroids haven't been used widely to date is because results from prior cohorts have been mixed (inc increased mortaltiy) & there has been a concern steroids lead to secondary bacterial infections & increase viral load.
https://www.nature.com/articles/s41375-020-0848-3 https://www.sciencedirect.com/science/article/pii/S1386653204001957?via%3Dihub
https://www.nature.com/articles/s41375-020-0848-3 https://www.sciencedirect.com/science/article/pii/S1386653204001957?via%3Dihub
Which is why WHO and NIH have recommended against it.
https://www.covid19treatmentguidelines.nih.gov/concomitant-medications/
https://apps.who.int/iris/bitstream/handle/10665/331446/WHO-2019-nCoV-clinical-2020.4-eng.pdf?sequence=1&isAllowed=y
https://www.covid19treatmentguidelines.nih.gov/concomitant-medications/
https://apps.who.int/iris/bitstream/handle/10665/331446/WHO-2019-nCoV-clinical-2020.4-eng.pdf?sequence=1&isAllowed=y
I would be willing to believe the current data as this is a study with better methodology and control arm and because other cohorts have shown benefits in severe cases. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2763184
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.
Steroids are used in acute respiratory distress syndrome (ARDS) but results there are mixed, and benefit of low dose steroids also seems to be limited to certain etiologies & patient subgroups. https://emcrit.org/pulmcrit/dexa-ards/
Overall, I think this is good news. Steroids are CHEAP. And with more data made available, ICU docs are likely to employ in mechanically ventilated patients who are not improving.
Here is the result to released results: https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_final.pdf
Oh also steroids are universally available (including in low and middle income countries) so I make an appeal to RECOVERY trial investigators to make the data available ASAP.
In summary:
1) Steroids are not a cure but if data holds out, great news for treating COVID19 patients sick enough to need mechanical vent.
2) Steroids are cheap & universally available
2) Please release data ASAP so guidelines can reflect if current practice should be changed.
1) Steroids are not a cure but if data holds out, great news for treating COVID19 patients sick enough to need mechanical vent.
2) Steroids are cheap & universally available
2) Please release data ASAP so guidelines can reflect if current practice should be changed.
One last thing: please do not take steroids for COVID19. evidence actually shows that given earlier in disease makes virus concentration higher. Steroids have severe side effects.
And you do not want to suppress your healthy immune system as it fights this disease.
And you do not want to suppress your healthy immune system as it fights this disease.
Unless prescribed by your doc (of course). Fin.
Last point. Lot of people tweeting on remdesivir vs steroids. These are different drugs working on different phases of disease. Ideally you want to combine a drug that ⬇︎ virus concentration early & one that ⬇︎ immune damage later. Not mutually excl. & potentially synergistic
