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International clinical trials published on Wednesday confirm the hope that cheap and widely available steroids can help seriously ill patients survive Covid-19, the disease caused by the coronavirus.
Based on the new evidence, the World Health Organization issued a new treatment guide, strongly recommending steroids to treat critically ill patients, but not those with mild disease.
“Clearly steroids are now the standard of care,” said Dr. Howard C. Bauchner, editor-in-chief of JAMA, which has published five articles on the treatment.
The new studies include an analysis that gathered data from seven randomized clinical trials that evaluated three steroids in more than 1,700 patients. The study concluded that each of the three drugs reduced the risk of death.
JAMA published that article and three related studies, along with an editorial describing the research as an “important step forward in treating patients with Covid-19.”
Corticosteroids should now be the first-line treatment for critically ill patients, the authors said. The only other drug that has been shown to be effective in seriously ill patients, and only modestly, is remdesivir.
Doctors often use steroids such as dexamethasone, hydrocortisone, and methylprednisolone to control the body’s immune system and relieve inflammation, swelling, and pain. Many Covid-19 patients die not from the virus, but from the body’s overreaction to the infection.
In June, researchers from the University of Oxford found that dexamethasone improved survival rates in seriously ill patients. The researchers hoped that other inexpensive steroids could help these patients.
Evidence was lacking: After the Oxford researchers made their announcement, some clinical trials of steroids were stopped, as doctors hated to deny what appeared to be an effective treatment to study participants.
Steroids can have harmful side effects, especially in elderly patients, who make up the majority of very sick coronavirus patients. Medications can leave patients vulnerable to other infections, can raise blood glucose levels, and can cause confusion and delirium.
In clinical trials, only the sickest patients were treated with steroids and it is not certain that those who are less ill will benefit or be harmed. It is also necessary to identify the optimal doses and duration of treatment.
But most of all, the scientists said, the new studies seemed to confirm the promise of this class of drugs for seriously ill patients with Covid-19.
The studies “are like the second hit of a double,” said Dr. Derek C. Angus, chairman of the department of intensive care medicine at the University of Pittsburgh, a co-author of one of the new studies and the analysis. .
“I had a big smile on my face when I saw the results,” added Dr. Angus. “This is a case of, ‘A question asked, a question answered,’ and that’s very rare.”
Analysis of the pooled data found that steroids were linked to a one-third reduction in deaths among critically ill Covid-19 patients. Dexamethasone produced a 36 percent drop in deaths in 1,282 patients treated in three separate trials.
Hydrocortisone, tested in 374 patients in three trials, appeared to reduce deaths by 31 percent, and a small trial of methylprednisolone in 47 patients resulted in a 9 percent drop in deaths. The analysis was conducted by a WHO task force that is striving to rapidly evaluate Covid-19 therapies.
Taken together, the new studies will bolster confidence in steroid use and address any lingering doubts on the part of some clinicians, said Dr. Todd Rice, associate professor of medicine and a physician of intensive care at the University of California School of Medicine. Vanderbilt.
The coronavirus outbreak>
Frequent questions
Updated September 1, 2020
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Why is it safer to spend time together outdoors?
- Outdoor gatherings reduce risk because viral droplets are dispersed by wind and sunlight can kill some of the viruses. Open spaces prevent the virus from accumulating in concentrated amounts and being inhaled, which can happen when infected people exhale into a confined space for long periods of time, said Dr. Julian W. Tang, a virologist at the University of Leicester .
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What are the symptoms of the coronavirus?
- At first, the coronavirus appeared to be primarily a respiratory illness – many patients had fever and chills, were weak and tired, and were coughing a lot, although some people don’t show many symptoms at all. Those who appeared the sickest had pneumonia or acute respiratory distress syndrome and received supplemental oxygen. By now, doctors have identified many more symptoms and syndromes. In April, the CDC added a sore throat, fever, chills and muscle aches to the list of early signs. Gastrointestinal complaints, such as diarrhea and nausea, have also been observed. Another telltale sign of infection can be a sudden and profound decrease in the sense of smell and taste. In some cases, teens and young adults have developed painful red and purple lesions on their fingers and toes, dubbed “covid toe,” but some other serious symptoms.
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Why does it help to be six feet from others?
- The coronavirus is mainly transmitted through droplets from the mouth and nose, especially when you cough or sneeze. The CDC, one of the organizations that uses that measure, bases its six-foot recommendation on the idea that most of the large droplets that people expel when they cough or sneeze will hit the ground within six feet. But six feet has never been a magic number that guarantees complete protection. Sneezing, for example, can send droplets more than six feet, according to a recent study. It’s a general rule of thumb: it’s safest to stand six feet away outside, especially when it’s windy. But keep a mask on at all times, even when you think you are far enough away.
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I have antibodies. Am I now immune?
- As of now, that seems likely, for at least several months. There have been terrifying accounts of people experiencing what appears to be a second episode of Covid-19. But experts say these patients can have a prolonged course of infection, and the virus takes a slow number of weeks to months after initial exposure. People infected with the coronavirus often produce immune molecules called antibodies, which are protective proteins that are produced in response to infection. These antibodies can last in the body for only two to three months, which may sound worrisome, but that’s perfectly normal after an acute infection subsides, said Dr. Michael Mina, an immunologist at Harvard University. It is possible that you will contract the coronavirus again, but it is highly unlikely that it will be possible in a short time from the initial infection or that it will make people sick a second time.
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What are my rights if I am concerned about going back to work?
In a new guideline, the WHO warned against indiscriminate use of steroids, emphasizing that patients who are not seriously ill are unlikely to benefit and may suffer from side effects. Unjustified use could deplete global supplies, depriving patients who really need the drugs.
The health organization began work on its guide in June, shortly after the University of Oxford published a preliminary report of its findings, partnering with researchers from seven clinical trials to conduct a meta-analysis and provide additional evidence in the fastest way possible. WHO officials. said.
They characterized the quality of the evidence in favor of steroid therapy for seriously ill patients as “moderate certainty”.
Among the other studies published Wednesday was a Brazilian trial of 299 patients with acute respiratory distress syndrome that compared dexamethasone treatment with regular care. The steroid significantly improved outcomes, increasing the number of days that patients were alive and without mechanical ventilation.
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Another study in France evaluated low doses of another steroid, hydrocortisone, in 148 patients. Those who received the drug were more likely to survive, but the results were not statistically significant because the trial was stopped early.
A third study tested different hydrocortisone regimens in 400 seriously ill Covid-19 patients in eight countries. It was also stopped prematurely, but the researchers concluded that there was a high probability that the treatment would improve outcomes.
When the Oxford results were announced in June, doctors around the world began using dexamethasone. “I think there was some uncertainty as to whether the effect was real,” said Dr. Rice, co-author of an editorial accompanying the new JAMA articles.
“This shows us that steroids are clearly beneficial in this population and clearly should be given, unless you can’t for some reason, which must be a pretty rare occasion.”
The drug remdesivir modestly shortens recovery time in critically ill Covid-19 patients, he noted, but it has not been shown to reduce deaths. “People are dying from this disease and we want a treatment that we are confident will decrease mortality and save people’s lives,” said Dr. Rice.
