Finally some good news today dexamethasone is now being called a major breakthrough based on a recent randomized controlled trial in the UK. Dexamethasone also known as Decadron is an example of a glucocorticoid are sometimes referred to as corticosteroids other examples of glucocorticoids include hydrocortisone methyl prednisolone prednisolone, prednisone beta methazone and triamcinolone so glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor in the body cortisol aka hydrocortisone is the glucocorticoid.
We naturally make in our body it’s essential for life it regulates or supports various cardiovascular metabolic and homeostatic functions it also plays a big role in our immune system especially when it comes to reducing certain aspects of inflammation this is why we use them all the time in medicine we sometimes give these steroids for asthma copd rheumatologic type diseases and countless more diseases. Sometimes it is also given for steroids for meningitis and also for some forms of cancer we also give them in the early course of severe ards acute respiratory distress syndrome whether that ards is due to infection such as pneumonia or vaping lung injury or whatever the cause for severe ards we typically give methylprednisolone or solumedral at a dose of one milligram per kilogram per day. So, for most people that ends up being around 80 milligrams per day so this is the equivalent of 15 milligrams of dexamethasone the idea here is to suppress the cytokine storm that has taken place meaning that the massive amount of inflammation that causes lung damage and can indirectly cause damage to other organs as well our body naturally makes cortisol in our adrenal glands specifically in the zona fasciculata of the adrenal cortex the adrenal gland then secretes cortisol into the bloodstream and the cortisol travels to different tissues of the body and then binds to the glucocorticoid receptor inside cells it then stimulates the cell to make more anti-inflammatory proteins and causes the cell to make less pro-inflammatory proteins but giving someone glucocorticoids meaning steroids to someone who has an infection is somewhat of a tricky thing because the fear is that if you suppress the body’s immune system it has the potential to make the infection worse. Sometimes the body’s immune system does more damage than the actual infection for example in cases of meningitis that is due to either streptococcus or tuberculosis we give steroids because the medical evidence shows that they have better outcomes when we do so and giving someone steroids for viral pneumonias like influenza is more controversial because doing so generally leads to worse infection with that said if the viral pneumonia is so bad to the point of causing severe ards most doctors will give steroids in that situation. So this is why, the general medical guidelines so far recommend against giving steroids for covert pneumonia unless the patient has severe ards and we’ve been waiting for randomized controlled trials to come out for steroids in covid and here we are now with this study so in march of 2020 the recovery trial which stands for randomized evaluation of covid-19 therapy was one of the randomized control trials that actually looked at several different potential treatments for covid which included low-dose dexamethasone this trial was done in the UK.
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Over 11 500 patients in it so this trial has not been peer reviewed as of has not been published in the journal yet so everything I know so far is based on what’s been released to the general public in this trial over 2100 patients were randomized to receive dexamethasone specifically six milligrams once per day for 10 days and this group was compared with over 4 300 patients that were randomized to the standard care alone so 6 milligrams of dexamethasone is the equivalent of 32 milligrams of methylprednisolone so this is about half the dose we would typically use for someone with severe ards so among the patients who received standard care alone 20-day mortality was highest in those who required mechanical ventilation this was 41 and then intermediate in those patients who required supplemental oxygen only this was mortality rate of 25 percent and the mortality rate was lowest among those who did not require supplemental oxygen in which that mortality rate was 13 for patients who were on mechanical ventilators dexamethasone reduced mortality from 41 percent to 28 percent for patients who needed supplemental oxygen it reduced mortality from 25 percent to 20 percent and there was no benefit among those patients who do not require supplement oxygen in other words if someone only had mild disease there was no point in giving dexamethasone so based on these results one death would be prevented by the treatment of around eight ventilated patients. So that’s the number needed to treat for ventilated patients and then the number needed to treat for the ones who required supplemental oxygen that number needed to treat would be 25 so these preliminary results are significant but it doesn’t mean that dexamethasone is a miracle drug it’s certainly not a cure but it does seem to help based on these numbers index and methazone could be of huge benefit and not just rich countries but poorer countries as well because this drug is very cheap and is widely available so this is great news and very exciting but there are still a lot of questions that need to be answered like what is the ideal dose should we use higher doses in patients who are mechanically ventilated with ards and when will it be approved for use in the united states and we’ll get these answers pretty soon now another.
Interesting question is should we give decadron dexamethasone to people who have mild disease now even though this study didn’t show any benefit the reason why i bring this up is because some people start out with mild disease and then go on to have moderate or severe disease and we have no way of predicting who goes on to do that and also it happens very quickly lots of times someone could be doing just fine and then all of a sudden within hours they all of a sudden are deteriorating and they have severe disease so should we give those patients decadron regardless is there any harm doing so that’s another question that remains to be seen.