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Features & Columns

WHO Endorses Steroid Treatment for Severe COVID-19 Patients

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WHO Endorses Steroid Treatment for Severe COVID-19 Patients

2020-09-03 16:37:42

By Laura Tucker, Staff writer; Image: Spilled bottle of pills (Image source: Public domain)

Another advancement was made in the treatment of the coronavirus with the World Health Organization citing evidence from three newly-published trials. These show that steroid treatment is effective for treating severe COVID-19 patients.

Finding such a treatment is "electrifying ... it gives us hope. Maybe we're gaining on this virus," said a doctor not involved in the studies, Todd R. Rice, a critical care physician at Vanderbilt University Medical Center.

This backs up findings in the United States. Earlier this summer the U.S. National Institutes of Health recommended using a synthetic steroid, dexamethasone, to treat patients placed on ventilators or who require oxygen.

Three news studies were sponsored by the WHO, along with four other randomized controlled trials. Each involved a corticosteroid.

"These three trials, and then the World Health Organization meta-analysis, sets steroids as the standard, and the expectation that patients are critically ill will get treated with this," added Rice.

The WHO analysis concluded that corticosteroids reduced deaths in critically ill patients by 20 percent. Another steroid, hydrocortisone, had similar benefits.

"Corticosteroids are the only treatment that has been conclusively demonstrated to reduce mortality in patients with COVID-19," said an author of the meta-analysis, Johnathan Sterne, an expert in medical statistics at Britain's University of Bristol.

"These results strengthen the evidence that doctors should treat critically ill COVID-19 patients with corticosteroids, unless there is a strong reason not to do so based on the circumstances of the individual patients," added Sterne.

A British clinical trial, Recovery, proved Dexamethasone to be the first medication to increase the odds of survival in patients deemed to have severe COVID-19. These results were published back in June.

"The Recovery trial was a fantastic trial. But even though it was a great trial, it was viewed by many as simply one trial," said University of Pittsburgh critical care doctor Derek C. Angus, an author of the hydrocortisone trial. "People wondered about generalizability."

The newest findings should answer those remaining questions. "When we see that this is the very consistent signal of benefit across different trials, that's very exciting," said Hallie Prescott, a University of Michigan Health System pulmonary and critical care doctor.

"At the beginning of this pandemic, we were hesitant, and we advised against" corticosteroids because of shortcomings in past respiratory illnesses, said Janet V. Diaz, a physician and clinical management lead for the WHO's health emergencies program.

But the advice was changed, based on the pooled trial results that show "if you give corticosteroids, you will have 87 fewer deaths per 1,000 patients" in the worst cases, added Diaz.

The three new trials were published in the Journal of the American Medical Association. They included COVID-19 patients in ICUs throughout the world. One studied dexamethasone in 299 patients in Brazil, another tested hydrocortisone in low doses in 76 patients against 73 who received a placebo in France, and a third from the U.S. and seven other countries analyzed 379 patients to test hydrocortisone.

The trials were halted in June after the British trial results became published. It was decided it would be uncomfortable, and perhaps unethical, for doctors to give patients placebos in randomized trials. This stopped the trials from being as statistically powerful as the researchers would have liked.

"The steroids are pretty much readily available, and they're not really expensive," said Rice. That's true in the U.S. as well as in lower-income countries.

There were some questions left unanswered in these trials. One important question is how to determine which patients are most likely to be helped by corticosteroids.

Prescott believes doctors will probably agree ICU patients on mechanical ventilation or significant respiratory support should receive steroids. However, she believes patients in the "gray zone" need to be case by case.

"Just because steroids work in sicker patients does not mean to say that we should be cavalierly starting steroids in every patient," said Angus. Many "don't need these big-gun drugs that suppress the immune system broadly." 

Future studies of the corticosteroids will determine duration and dosages. Prescott noted a Denmark trial has already started to evaluate high vs. low doses.

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