Now four steroids are recommended against covid-19. They can help the sickest patients.

WHO has given the green light to the drug in collaboration with a Norwegian foundation. The recommendation has been made in record time.

The treatment should be able to reduce COVID-19 mortality by 21 percent if given to the sickest patients, according to the WHO.

There are four steroids: dexamethasone, prednisone, methylprednisolone, and hydrocortisone. All are in use in Norway, but so far only dexamethasone has been used in patients with Covid-19.

– Clinicians and doctors are very used to using steroids in treatment. It is cheap and easily accessible in all countries. This is a breakthrough, says Per Olav Vandvik.

He is a physician at Lovisenberg Diakonale Hospital, a principal investigator at the National Institute of Public Health, and a professor of medicine at the University of Oslo.

Vandvik also runs MAGIC, a Norwegian non-profit foundation that works pro bono (voluntarily and without funding) for the WHO. The foundation works to provide credible and up-to-date decision support to health authorities and health personnel internationally.

Decision support means the information base necessary to provide the appropriate treatment or medication.

Two recommendations

The WHO guidance panel consists of 23 experts from various countries who have been designated and screened for conflicts of interest. They consider and decide what the recommendation should be.

MAGIC helps with the knowledge base on which the recommendation is based and provides methodological support to experts, according to Vandvik.

– Steroids are only recommended for critically ill patients. Steroids such as hydrocortisone have been used for many years, including treating allergies, carbon monoxide, and asthma exacerbations. They are also used for various connective tissue diseases and in anti-inflammatory treatments, he says.

The WHO panel concluded that the drugs can be recommended to all or almost all patients with severe or critical COVID-19, as studies show a significant reduction in mortality in these patients.

The four drugs that are now getting the green light from the WHO have been tested in seven studies in COVID-19 patients. Three of the studies are published on the same day as the WHO recommendations.

The largest study used is the British Recovery Study, which concluded that the lives of 5,000 COVID-19 victims could have been saved in the UK if the drug had been used since the start of the outbreak.

When Recovery announced the new discovery in June, CEO John-Arne Røttingen of the Research Council of Norway described the discovery as “good news”.

– This will likely have consequences for what is considered the best standard treatment, that is, the best treatment given the knowledge we have for patients with covid-19, Røttingen told Aftenposten.

– Hospitals need good guidelines

– Every health service needs to systematically review the knowledge about the treatment provided. A country like Norway also needs good guidelines for hospitals, especially for Covid-19, Vandvik says.

A guide is a way to ensure that treatment is used appropriately so that it is not the individual physician who determines whether a treatment is appropriate for the patient.

– If the WHO had spent three years on this, the race would have been run

Traditionally, it has taken up to three years to update a guide. The covid-19 pandemic has changed this. In the case of the new guidelines for steroids, explains Vandvik, they have managed to immediately develop credible recommendations in real time. He thinks this is a breakthrough.

– In the covid-19 pandemic, up-to-date and credible knowledge is absolutely crucial. If the WHO had spent months and years on this, the race would have been run. So it would have been up to each individual country to do the job itself, he says.

Explain that since new knowledge comes in all the time and one uses it for a long time, the knowledge will be out of date before the guide is published.

– Health professionals and patients need access to that knowledge, he says.

– We have been working on this guideline since the recovery study press release arrived in June. When we received the data from the other studies, it took a week, Vandvik says.

Vandvik says the WHO has access to unpublished and as yet non-peer-reviewed studies in the work of finding a treatment for COVID-19, and that these have been crucial in the work with recommending steroids. WHO has chosen to wait with publication until the latest studies that have been used have also been published. This is done to ensure the information is correct, explains Vandvik.

– You have used data from studies that were not published and peer-reviewed when the work was done, and the information processing is done in days and weeks. How can you ensure that the information you use is correct?

– The time it takes to prepare a guide for a treatment of several months and years can be reduced to days and weeks without compromising quality. MAGIC is based on summary knowledge, not individual studies. We follow internationally established standards for credible guidelines, says Vandvik.

There is uncertainty about the method.

He admits that there is uncertainty about the knowledge base for steroid use.

– Although we are based on good studies, we have said that there is still some uncertainty in the knowledge base. However, the basis is good enough for WHO to make a strong recommendation. In this case, it is important to emphasize that the recommended drug is not recommended for people with mild illness. If anything, treatment can increase mortality, Vandvik says.

MAGIC is also working with the British Medical Journal (BMJ) on the project “BMJ Quick Recommendations”. A team of doctors, patients and researchers processes the information from published studies on an ongoing basis in order to provide updated guidelines according to health authority standards in a short time and in easy-to-use formats.

The new WHO guideline will also be posted here.

“Rapidly developed guidelines can prevent misuse at an early stage,” says Vandvik, referring to the controversial antimalarial drug hydroxychloroquine.

The United States quickly acquired large quantities of the drug, although it had not yet been fully tested and approved for use in patients with COVID-19. The president of the United States also publicly recommended the drug, saying that he had used it himself. It later turned out that the drug had no effect against covid-19.