Dexamethasone for COVID-19: Some US Hospitals Wait to Change Practice

Jillian Mock

June 19, 2020

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Following the announcement earlier this week that dexamethasone reduced mortality for severely ill COVID-19 patients in a randomized clinical trial, doctors at some US hospitals are hesitant to change treatment protocols, whereas others say they have been prescribing steroids for months already. 

Researchers at the UK National Health Service (NHS) and the University of Oxford decided to halt the low-dose dexamethasone group of its RECOVERY trial early and announce the findings in a press release Tuesday before submitting the data for peer review. The treatment is the first shown to reduce mortality in COVID-19 patients, one of the principal investigators said. 

Based on those findings, the national medical director for the NHS and the chief medical officers of Wales, Scotland, Northern Ireland, and England recommended in a joint statement that physicians should change practice without waiting for the data's full publication, "given this clear mortality advantage, with good significance, and with a well-known medicine which is safe under these circumstances." 

However, response to the announcement in the US medical community has been mixed. Some experts, including physicians who have used steroids to treat COVID-19 patients, greeted the news enthusiastically, and encouraged their colleagues to consider steroids as treatment for seriously ill patients sooner rather than later. 

"To me it is not a surprise, but a relief. It validates some of the therapies I've given and gives us something, finally, that decreases mortality" said Hugh Cassiere, MD, director of critical care medicine, Northwell Health's North Shore University Hospital in Manhasset, New York.  

Yet others are skeptical of the findings given the way the UK researchers announced the results. "My first reaction is we've done this before with hydroxychloroquine," said James Town, MD, medical director of the medical intensive care unit at Harborview Medical Center and assistant professor at the University of Washington School of Medicine, Seattle.

The first reports of hydroxychloroquine were optimistic about its potential and physicians "latched on to" it as a possible therapy before the data were closely examined or the findings replicated, said Town. But in practice the therapy has not been shown to be effective, and may even be harmful. 

"Now when we see it happen again, I am personally a little more wary over changing practice based on just a press release at this point," he said. 

Town says his hesitancy is shared by colleagues at the University of Washington. Steroids have not been shown to be effective in patients with SARS and MERS, and instead may prolong viral shedding, he notes. Research also suggests patients with influenza pneumonia worsen on steroids.

Town is hopeful the findings from RECOVERY will turn out to be as positive as the press release suggests and notes the credibility of the researchers behind the findings. But he and his colleagues are waiting to see if the data are enough to make a practice-changing decision or if more trials and replication are needed. 

While other doctors reiterated the need to see the full study as quickly as possible, they insisted the findings are so important the researchers had an ethical obligation to share the results immediately, without waiting several additional weeks to undergo peer review. "I think this is an issue of such enormous global public health impact, I don't think the authors had any choice but to make their findings immediately known," said Adam Gaffney, MD, MPH, a pulmonary critical care physician at Harvard Medical School in Boston, Massachusetts, and Cambridge Health Alliance. 

"I think that whenever there's a randomized clinical trial that gets stopped early for a mortality benefit that the information is of critical importance," says Paul Sax, MD, an infectious disease physician at Brigham and Women's Hospital in Boston. "When a data safety monitoring board stops a study based on a difference in survival, people should take notice because that does not happen all the time."

Until now, the use of steroids to combat COVID-19 has varied widely by institution and practicing physician, says Sax. At Brigham and Women's, the general recommendation has been not to use them thus far. But Sax feels confident the hospital will reconsider that position in light of this finding. 

Some Physicians Already Prescribing Steroids

Meanwhile, Cassiere said he started administering dexamethasone to COVID-19 patients in March, using research published earlier this year that found the drug was effective against acute respiratory distress syndrome (ARDS) as a guide. The benefits were clear almost immediately, he says. The first severely ill COVID-19 patient Cassiere treated with dexamethasone showed dramatic recovery within just 48 to 72 hours, he said. About one third of patients given the steroid recovered as a result, he estimates. 

Given this experience, Cassiere had already advised Northwell Health's pharmacy department to stock up on dexamethasone prior to the RECOVERY trial announcement this week, to prepare should cases spike again in New York City, he says. While Cassiere was already planning to use the steroid during a possible COVID-19 resurgence, he says this finding gives him much more confidence that dexamethasone could soon become the standard of care. 

Intensive care physicians at NYU Langone Health also started administering high doses of another steroid, methylprednisolone, to critically ill COVID-19 patients when the pandemic took off in New York City. Although steroids can suppress the immune system, Sam Parnia, MD, PhD, associate professor of medicine and director of critical care and resuscitation research at NYU Langone, and his colleagues suspected it was the immune system response, not the virus, killing their patients. After administering the steroid, patient oxygen requirements would go down quickly and substantially, and their pneumonia symptoms would get better quickly, but would surge back if steroids were stopped. 

"I am very excited by it. I genuinely cannot overstate how important this is," Parnia said of the RECOVERY trial announcement. 

Moreover, Parnia said these results cannot be compared to the retracted hydroxychloroquine studies, which were the result of a pooled data analysis. Instead, these results are from a randomized controlled trial from a respected group of researchers. Given the strength of the statistical significance reported in this initial announcement, Parnia says he does not expect peer review to drastically alter the final results. 

All the physicians interviewed for this story said they hope to see the full dataset as soon as possible, to guide clinical practice as well as influence future COVID-19 research. "But in the meantime, people faced with critically ill patients as of today," said Sax, "have to strongly consider this intervention based on the information we have."

Jillian Mock is a freelance science journalist based in New York City. She writes about healthcare, climate change, and the environment and her work has appeared in many publications including the New York Times, Audubon Magazine, and Scientific American. 

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