A Closer Look at the Steroid Dexamethasone for COVID-19

A Closer Look at the Steroid Dexamethasone for COVID-19
A Closer Look at the Steroid Dexamethasone for COVID-19
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Dexamethasone, a cheap steroid medication that has been around for decades, was shown in a new, large trial to reduce deaths in hospitalized patients with COVID-19. This news is exciting and promising, yet the risks and side effects associated with this drug haven’t been widely discussed, and so to say that dexamethasone should become the new standard of care for hospitalized COVID-19 is most certainly jumping the gun. 

Corticosteroids like dexamethasone are associated with side effects, such as high blood pressure, osteoporosis, high blood sugar, blurry vision, and a higher risk of infections — which can be problematic with patients who have some pre-existing conditions like heart disease, high blood pressure, or diabetes. If you are taking a diabetes drug, the amount of dexamethasone might need to be adjusted. 

Indeed, steroids work by reducing the activity of the immune system, which could lower the body’s resistance to other infections. Oral corticosteroids also have the greatest risk of side effects, so taking it via an inhaler or injection could reduce that risk.

In addition, dexamethasone is known to interact with many other drugs. Here’s a quick breakdown:

  • Patients who are taking blood thinners Eliquis (apixaban) and Xarelto (rivaroxaban), dexamethasone can lower the amount of corticosteroid in your blood. 
  • Caution should also be taken with HIV medications, such as protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and integrase inhibitors, as taking them in combination with dexamethasone can reduce the levels of these antivirals in your blood.  
  • Taking dexamethasone with the antibiotic erythromycin or an antifungal like ketoconazole can increase the level of dexamethasone in your blood, making it more potent and possibly triggering increased side effects. 
  • And taking diuretics (water pills) such as furosemide and bumetanide with dexamethasone can lower levels of potassium in the body. This mineral is important for muscles, nerves, and organs to work normally, so low levels of potassium can lead to muscle cramps, tiredness, and even irregular heartbeat. 

The new results are part of the UK’s RECOVERY trial, which is testing several existing medications to see if they might also work for COVID-19. One of the arms is testing dexamethasone, which is used to treat many conditions, including arthritis, lupus, and psoriasis because of its anti-inflammatory properties.

Around 2,100 patients were given dexamethasone for 10 days and compared to about 4,300 patients who received usual care. Preliminary results released this week found that those in the dexamethasone group on a respirator saw their risk of death reduced by one-third and by 20% in patients on oxygen compared to the usual care group. There was no benefit seen in patients who didn’t require some type of breathing support. 

The findings are significant in that they indicate dexamethasone may reduce deaths in patients with COVID-19. According to the information released, “Based on these results, 1 death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.”

But before doctors potentially turn to off-label use of dexamethasone or the FDA grants an emergency use authorization for the drug as a COVID-19 treatment, there are several important caveats. The results that were released were preliminary and once the full datasets are published, they will undergo peer review and further scrutiny. Second, the findings have yet to be replicated in another large, randomized, controlled trial to confirm the RECOVERY findings. Third, the benefits were only seen in very ill patients with COVID-19, so it’s unclear if similar results would be seen in those with milder cases of the virus. 

“Researchers will be keen to…critically analyze the details, confirm the rigor of the study, and also explore broader issues of potential harmful effects of dexamethasone to see how the results can be translated into the clinical care of critically unwell people with COVID-19,” said Andrew McLachlan, Dean of Pharmacy in the Sydney Pharmacy School at the University of Sydney. 

The results also came a week after The Lancet retracted a major study on hydroxychloroquine for COVID-19, another drug that had been touted by some as a promising treatment. That has left some experts a bit skeptical.  

“It will be great news if dexamethasone…really does cut deaths by one-third in ventilated patients with COVID 19, but after all the retractions, it is unacceptable to tout study results by press release without releasing the paper,” Atul Gawande, MD, MPH, a well-respected surgeon, and writer, Tweeted.

While many observers are optimistic about the dexamethasone preliminary results, it’s too early to jump to conclusions. Closer examination of the complete data, once released, will give a better picture of whether the optimism is warranted.

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