Dexamethasone and Corticosteroids
Written by Justin Nguyen, Edited by Maura McDonagh and Sami Morse
As then-President Donald Trump recovered from COVID-19 in October 2020, he raised questions from the medical community as to the effectiveness of a reported “experimental drug cocktail” that he was provided at Walter Reed Hospital while being treated. One of such treatments included dexamethasone, which is currently approved by the FDA for prescribed medical use, and has shown promise in reducing the effects of COVID-19.
Properties and Uses
Dexamethasone is part of a larger family of medications called corticosteroids. Corticosteroids are hydrophobic agents that mimic the properties of cortisol. Cortisol is a hormone released in response to stress by the adrenal glands in the kidneys, a process set in motion by other glands in the endocrine system. It is known to suppress the immune response to several infections and inflammatory symptoms. Corticosteroids mimic cortisol’s effects by binding to cortisol receptors on target cells, thus helping to reduce inflammation. SARS-CoV-2 primarily afflicts patients due to inflammation in the lungs, leading to pneumonia-like effects. On account of this inflammation, alveoli, sacs of air in the lungs, swell and fill with fluid, leading to reduced oxygen exchange between the lungs and blood, causing shortness of breath. In extreme cases, this may progress to acute respiratory distress syndrome, requiring hospitalization. Corticosteroids, including dexamethasone, reduce the inflammatory response in the lungs, alleviating respiration and aiding recovery.
Corticosteroids are taken orally or intravenously on a dose of 6 mg daily for 10 days, but only are recommended for patients developing moderate to severe symptoms for COVID-19.
RECOVERY Trial and Clinical Implications
The RECOVERY study sought to clinically test dexamethasone on a randomized placebo-controlled trial to survey effects on COVID-19 (n=6425). Of the study population, 89% were laboratory-confirmed COVID-19 patients, 16% required ventilation, 60% required supplemental oxygen, and 24% did not require oxygen supplementation. In the dexamethasone experimental group, researchers found a significantly lower incidence of death in patients who required mechanical ventilation and in patients who required supplemental oxygen, but not for individuals who did not receive any respiratory support. Additionally, risk of progression to ventilation requirement decreased in the dexamethasone group compared with placebo.
In other words, results are promising for patients with severe symptoms undergoing mechanical ventilation or requiring supplemental oxygen, but not for individuals who do not require these techniques.
Some critics, notably the European Medicines Agency have some concerns regarding widespread dexamethasone usage without further investigation. Primarily, they cite smaller, retrospective cohort studies that suggest dexamethasone may not play a significant role in fighting COVID-19, and that the side effects from using the drug may outweigh the potential benefits. However, the United States and United Kingdom food and drug regulatory bodies have found the RECOVERY study sufficient and significant enough to approve its use for COVID-19.
INTERNATIONALLY: Dexamethasone has been prequalified for prescription use by the WHO for general inflammation, but is under review for COVID-19.
U.S and U.K: Per the results of the RECOVERY trial, the COVID-19 Treatment Guidelines Panel recommends using dexamethasone for only hospitalized patients with severe symptoms and/or on ventilation.
Documented anti-inflammatory effects on COVID-19 patients
Lower mortality rates and reduced risk of ventilation for those with severe symptoms
Readily available in supply and status is approved for medical use in the U.S.
Effects not well documented in two subgroups: pregnant women and children, but there is a general precedent for use of dexamethasone with these patients
Smaller retrospective cohort studies have reported risk factors of dexamethasone for multiorgan dysfunction and negligible effect on COVID-19.
Results from ongoing research and the current understanding of COVID-19 are constantly evolving. This post contains information that was last updated on May 3rd, 2021