Preliminary Report on the Benefits of Dexamethasone in Hospitalized Patients with Covid-19

by | Aug 4, 2020 | 2020, COVID-19, Lung Health

Written by Joyce Smith, BS. Study finds that dexamethasone shows promise as an inexpensive, readily available treatment for COVID-19.

hospital bedSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease (Covid-19), made its debut in Wuhan China in the late fall of 2019 1. While the majority of COVID-19 cases are asymptomatic or mild, this respiratory disease often requires prolonged ventilation 2. Remdezivir, an antiviral agent that inhibits viral replication by interfering with RNA, clearly offers a shortened recovery time 3; however, along with other therapeutic interventions, it has fails to control the overwhelming immune response that can lead to organ failure in a subset of patients who are particularly vulnerable. 4,5. Spurred by the highly debated use of glucocorticoids 6 as a potential therapeutic, Landray and colleagues 7 conducted the controlled, open-label Randomized Evaluation of Covid-19 Therapy (RECOVERY) trial of dexamethasone in hospitalized Covid-19 patients. They recruited patients who had confirmed or suspected COVID-19 infection from 176 National Health Service organizations across the U.K. The trial had a total of 2,104 patients randomly assigned to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days and 4,321 patients assigned to receive usual care. Also, at randomization 16% of those in the dexamethasone group received mechanical ventilation or extracorporeal membrane oxygenation, 60% received oxygen only, and 24% received neither. Participant mean age was approximately 66 years; 36% participants were female and included women who were pregnant or breastfeeding and girls. Over half of the patients had at least one chronic comorbidity, 27% had heart disease, 24% had diabetes, and 21% had chronic lung disease. Almost all patients in the dexamethasone group received at least one dose of the drug for a median duration of 7 days, while 8% of those in the usual care group received dexamethasone as part of their care. During the follow-up period, 25% of patients in each group received azithromycin. The primary outcome was 28-day mortality.

After comparing a range of possible participant treatments, researchers found that overall, significantly fewer patients (482) in the dexamethasone group (22.9%) compared to 1,110 patients (25.7%) in the usual care group, died within 28 days after randomization (P<0.001). Between-group differences in mortality varied considerably based on the level of respiratory support that the patients received at the time of randomization. Also, compared to those receiving usual care, the mortality rate was significantly lower for those in the dexamethasone group receiving mechanical ventilation (29.3% vs 41.4%), and among those receiving supplemental oxygen without mechanical ventilation (23.3% vs 26.2%) but not among those who were receiving no respiratory support (17.8% vs. 14.0%) at randomization.

When preliminary results were presented in June, the researchers believed that, based on the study findings, the use of dexamethasone could potentially prevent the death of one out of approximately eight ventilated patients, or one out of 25 patients requiring oxygen alone.

In an accompanying editorial 8 by Lane and Fauci, both believe that remdesivir is most effective in hospitalized patients with modest disease, while dexamethasone with its anti-inflammatory and immunosuppressive properties is most beneficial in patients who have more advanced disease  (at which time their immune and inflammatory responses are very high). The use of dexamethasone has already been endorsed by several treatment-guideline panels, including one by the U.S. National Institutes of Health 7  and is now becoming the standard of care for advanced patients on ventilators and/or for those requiring oxygen. They believe the recent results on dexamethasone provide “clarity to an area of therapeutic controversy and probably will result in many lives saved.” In addition to the current report on dexamethasone’s effectiveness, the RECOVERY team found hydroxychloroquine and  lopinavir–ritonavir to be ineffective and are presently exploring the benefits of dexamethasone in children, as well as potential benefits of azithromycin, tocilizumab, and convalescent plasma 9. Dexamethasone is an inexpensive drug and readily available for use worldwide.

Source: RECOVERY Collaborative Group. “Dexamethasone in Hospitalized Patients with Covid-19—Preliminary Report.” New England Journal of Medicine (2020).

Copyright © 2020 Massachusetts Medical Society.

Posted August 4, 2020.

Joyce Smith, BS, is a degreed laboratory technologist. She received her bachelor of arts with a major in Chemistry and a minor in Biology from  the University of Saskatchewan and her internship through the University of Saskatchewan College of Medicine and the Royal University Hospital in Saskatoon, Saskatchewan. She currently resides in Bloomingdale, IL.

References:

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  9. NIH. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. 2020; https://www.covid19treatmentguidelines.nih.gov/. Accessed July 30, 2020.