Dexamethasone.
Why is the medical world excited about it? Because the cheap and widely available steroid is a potential life-saving drug for critically ill COVID-19 patients. That’s what the researchers at the University of Oxford discovered.
In their study, the drug has been found to reduce the mortality of the sickest patients. Which is more like virtually pulling them away from the doorstep of death.
The medication is of no use to corona patients with mild symptoms, but that doesn’t matter. They don’t require hospitalisation. No medicines too, as their treatment is more symptomatic.
Critically ill patients
COVID-19 patients are generally hospitalised only when their lungs are affected. They will require assisted breathing. A patient on a ventilator is at a critical stage. So when a drug reduces deaths by one-third, that is enough cause for jubilation. It’s a life-saver! Until now, there have been no effective drugs to treat these dying patients. The drug is also found to be effective for patients who need oxygen support.
Researchers around the world have been working to find a cure for the highly contagious virus, SARS-CoV-2, which has infected more than 8 million people and killed nearly 450,000. Most of the attention was focused on repurposing existing antiviral drugs to reduce the turnaround time since they would have some of the necessary approvals. Avigan belongs to this group; versions of this drug are approved as COVID-19 treatment in China and Russia.
Amid this frantic research, comes dexamethasone. It’s no antiviral. It’s a corticosteroid, a synthetic one (The adrenal gland in the body naturally produces corticosteroids). And it’s affordable and readily available in most countries, although the trade names vary. Impoverished countries with COVID-10 patients will enormously benefit from that.
The steroid has been around for more than half a century. It’s been used to reduce inflammation and treat a range of conditions, including arthritis, asthma, immune system disorders, allergic reactions, cancer and some skin conditions. Which means it’s been in regular use and its side-effects and contraindications are well known. That allows physicians to take the necessary precautions before prescribing it. Hospitals in Britain have already begun to treat severely ill COVID-19 patients with dexamethasone from Tuesday.
How dexamethasone fights COVID-19
Three-fourth of the patients admitted to hospitals receive some form of oxygen. The more critical ones are put on ventilators.
In critically ill COVID-19 patients, the coronavirus attacks cells lining the airways and lungs. This can trigger an overwhelming immune reaction, known as the cytokine storm, which can be fatal.
In the study, dexamethasone has helped in reducing inflammation caused by the immune system, thereby protecting the tissues. It decreases the inflammation by preventing infection-fighting white blood cells from travelling to the area of swelling. (This is why patients on steroids are more prone to infection). The drug also works by altering the body’s immune system
What are the results of the trial?
The study by the University of Oxford is part of the world’s biggest trial, known as the RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial, which is testing existing treatments to fight the coronavirus. It randomly assigned 2,104 patients to receive dexamethasone 6mg once per day (by mouth or by intravenous injection) for 10 days. They were with 4,321 patients getting usual care alone.
After 28 days, the study found that dexamethasone had reduced deaths by 35 per cent in patients who required ventilation and by 20 per cent in those who only needed supplemental oxygen. It did not appear to help patients with mild illness.
Among the patients who received only usual care, mortality was highest (41 per cent) in those who needed treatment with breathing machines. Around 25 per cent of deaths were reported in patients who required only oxygen support, and the lowest death rate (13 per cent) was among those who did not need any respiratory support.
Dh161 to save a life
Prof Martin Landray, co-leading the trial, said the findings indicate that one life could be saved for £35. That would be around Dh161. “The treatment is up to 10 days of dexamethasone. It costs in the order of £5 for a complete course of treatment in the NHS,” he was quoted as saying.
“For less than £50 pounds, you can treat eight patients and save a life,” he said in an online briefing. One death would be prevented in every 25 COVID-19 patients on oxygen that received the drug, he calculated.
Can everyone use dexamethasone?
No, it works only on COVID-19 patients hospitalised with breathing difficulties. Which means they will be on ventilators or oxygen support.
People with mild illness are treated symptomatically. In most cases, paracetamol is enough.
Why active athletes shouldn't use it?
Dexamethasone is banned by the World Anti-Doping Agency (WADA) for athletes during competitions. But its usage is allowed out of competition, if athletes have Therapeutic Usage Exemption.
Why we have to be cautious
The study is yet to be peer viewed and published. After the recent retraction of a paper on hydroxychloroquine, published in the medical journal Lancet, we have to be more careful. It is easy to get carried away at the prospect of having a life-saving drug. Yet that enthusiasm has to be tempered with caution.
What is dexamethasone?
Dexamethasone is a corticosteroid hormone (glucocorticoid). The adrenal gland in the body naturally produces corticosteroids. Dexamethasone decreases your body’s natural defensive response and reduces symptoms such as swelling and allergic-type reactions.
First synthesised in 1957, dexamethasone was approved for medical use in 1961. It is on the World Health Organisation’s List of Essential Medicines.
The prescription medication (it can only be bought with prescription) is available as an oral tablet, oral solution, eye drops, and eardrops. It’s also available as an injectable solution or an intraocular solution given after surgery.
Trade names and other names
The general trade names are Decadron, Dexasone, Diodex, Hexadrol, Maxidex. In the United States, the brand names are Baycadron Elixer, Decadron, Dekpak 13 Day Taperpak, Dexamethasone Intensol, DexPak, DexPak 10 Day TaperPak, DexPak Jr and Zema-Pak. Other names are: dexamethasone sodium phosphate, dexamethasone acetate. It’s also available as a generic drug, costing less than the branded ones.
What are the uses of dexamethasone?
Before the COVID-19 breakthrough, dexamethasone has been used to treat a range of conditions. The website Chemocare lists the following uses:
■ As an anti-inflammatory medication. To reduce swelling, associated with tumours of the spine and brain, and to treat eye inflammation.
■ To treat or prevent allergic reactions.
■ As treatment for some autoimmune diseases, skin conditions, asthma and other lung conditions.
■ Against a variety of cancers, such as leukaemia, lymphoma, and multiple myeloma.
■ To prevent nausea and vomiting associated with some chemotherapy drugs.
■ Used to stimulate appetite in cancer patients with severe appetite problems.
■ To replace steroids due to adrenal insufficiency (low production of steroids produced by the adrenal glands)
What are the side-effects?
As with any medication, dexamethasone too has side-effects. So it has to be taken only under medication supervision.
Most patients won’t experience all the side-effects, and they are reversible. Some of the side-effects described by MedicinePlus, a website of the US National Library of Medicine, include: stomach upset, headache, dizziness, menstrual changes, disrupted sleeping, increased appetite, or weight gain. If any of these effects persist or worsen, the doctor has to be notified urgently.
What you should tell the doctor
The doctors will check your medical history before prescribing dexamethasone. A patient has the responsibility to tell the doctor of any condition the doctor is not aware of. It should cover previous instances of infections, reactions to other corticosteroids, kidney disease, liver disease, mental/mood conditions like psychosis, anxiety, depression, low blood minerals, thyroid disease, stomach/intestinal problems, high blood pressure, heart problems, diabetes, eye diseases, brittle bones (osteoporosis), and history of blood clots.
What is the RECOVERY trial
The RECOVERY trial is a large, randomised controlled trial of possible treatments for patients admitted to hospital with COVID-19. Over 11,500 patients have been randomised to the following treatment arms, or no additional treatment:
■ Lopinavir-Ritonavir (commonly used to treat HIV)
■ Dexamethasone (a type of steroid used to reduce inflammation)
■ Hydroxychloroquine (which has now been stopped due to lack of efficacy)
■ Azithromycin (a commonly used antibiotic)
■ Tocilizumab (an anti-inflammatory treatment given by injection)
■ Convalescent plasma (collected from donors who have recovered from COVID-19 and contains antibodies against the SARS-CoV-2 virus).
