What is dexamethasone? Trump is taking drug meant for severe Covid-19 patients after dip in oxygen level
President Donald Trump is being given the steroid dexamethasone as part of his Covid-19 treatment, according to his medical team, adding to the growing list of treatments for his illness. The team suggested that he was recovering fast and that they could even start planning his discharge from the hospital. "The fact of the matter is, is that he’s doing really well, that he is — he is responding. And as the team said, if everything continues to go well, we’re going to start discharge planning back to the White House," said White House physician Sean Conley during a briefing on September 5.
On the other hand, Conley also told reporters that Trump had received the steroid after his blood oxygen levels dropped twice below normal levels. "Over the course of his illness, the President has experienced two episodes of transient drops in his oxygen saturation (meaning his oxygen levels dropped too low). We debated the reasons for this and whether we’d even intervene. It was the determination of the team, based predominantly on the timeline from the initial diagnosis, that we initiate dexamethasone," he said.
Brian Garibaldi, one of Trump’s doctors, also said during the briefing that in response to transient low oxygen levels, "we did initiate dexamethasone therapy, and he received his first dose of that yesterday (October 4), and our plan is to continue that for the time being".
Does dexamethasone work for coronavirus patients?
What do the guidelines say about this widely available drug and to what extent does it help coronavirus patients? Both the National Institutes of Health (NIH) and the World Health Organization (WHO) recommend that doctors use dexamethasone to treat only serious cases of Covid-19.
Dexamethasone is a corticosteroid that has been used since the 1960s to reduce inflammation in a range of conditions, including inflammatory disorders and certain cancers. Dexamethasone has been shown to be beneficial in those with severe Covid-19 because it can stop the immune system from going into overdrive. When that happens, the immune system can do more harm than good, attacking the body in what is called a “cytokine storm". It was tested in hospitalized patients with Covid-19 in the UK’s national clinical trial recovery and was found to have benefits for critically ill patients. Eligible patients were randomly allocated between several treatment arms. Dexamethasone was administered as an oral (liquid or tablets) or intravenous preparation, at a dose of 6 mg once daily for 10 days, in one of the arms.
According to findings, for patients on ventilators, the treatment was shown to reduce death by about one third, and for patients requiring only oxygen, death was cut by about one fifth. However, no survival benefit was observed among the participants who did not require oxygen therapy at enrollment. "There was no evidence that dexamethasone provided any benefit among patients who were not receiving respiratory support at randomization, and the results were consistent with possible harm in this subgroup," wrote researchers.
The NIH issued a statement, which said that the preliminary results of the UK trial showed reduced mortality in patients randomized to receive dexamethasone compared to those who received standard of care. "The benefit was observed in patients with severe Covid-19 (defined as those who required supplemental oxygen) and was greatest in those who required mechanical ventilation at enrollment. No benefit of dexamethasone was observed in patients who did not require supplemental oxygen at enrollment," says the agency.
Based on the preliminary results, NIH Covid-19 treatment guidelines panel advised using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with coronavirus who are mechanically ventilated and in patients with Covid-19 who require supplemental oxygen but who are not mechanically ventilated. "(The panel) recommends against using dexamethasone in patients with Covid-19 who do not require supplemental oxygen," it says.
Steroid may harm those with non-severe Covid-19
The WHO also issued guidelines on September 2 advising that dexamethasone only be given to patients with "severe and critical Covid-19". The panel made two recommendations: a strong recommendation for systemic (that is, intravenous or oral) corticosteroid therapy (for example, 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours) for 7 to 10 days in patients with severe coronavirus, and a conditional recommendation not to use corticosteroid therapy in patients with non-severe coronavirus.
"We recommend systemic corticosteroids for the treatment of patients with severe and critical Covid-19. We suggest not to use corticosteroids in the treatment of patients with non-severe Covid-19 as the treatment brought no benefits, and could even prove harmful. Treatment should be under supervision of a clinician," the agency states. It adds, “Systemic corticosteroids may increase the risk of death when administered to patients with non-severe Covid-19."
Work on this guidance began on June 22 when the recovery trial published the initial report on the impact of corticosteroids. "Corticosteroids are listed in the WHO model list of essential medicines, readily available globally at a low cost. WHO encourages countries to maintain sufficient stocks of corticosteroids to treat Covid-19 and the other disease for which they are effective, while not maintaining excessive stocks which could deny other countries access," suggests the agency.