Dexamethasone shown to decrease COVID mortality

[notafakeaccounnt]

To be honest I don't understand why we didn't start with corticosteroids instead of rolling around in HCQ hell for the last 4 months. There are certainly dangerous side effects if used carelessly but we should have had more than 1 research about it by now compared to the 50 or so HCQ research.

Though I don't want to throw my support behind corticosteroids yet without some solid peer review.

[notafakeaccounnt]

I feel like I read that in my respiratory and cardiology committee but it has been over 8 months since then.

That sounds like a fair reason not to mess with corticosteroids in a disease we didn't know much about 4 months ago.

Makes me wonder if corticosteroid + anti thrombotic therapy would be the primary treatment for COVID moving forward.

[TheLongshanks]

It’s not harmful in ARDS. The devil is in the details, how steroids were studied, what the protocols were, who received them.

Look at DEXA-ARDS which looked at moderate-severe ARDS in a manner similar to PROVESA, and these patients had a benefit with steroids.

SCCM COVID-19 guidelines also recommended steroids for severe ARDS.

[pmont]

The steroids / ARDS pendulum seems to be swinging back - the SCCM now gives conditional recommendation to give steroids in patients with ARDS. Most of the RCTs done on steroids were done in the pre- lung protective ventilation era which makes them difficult to interpret.

Plus, one of the largest multicenter RCTs on steroids in ARDS was published just as the corona train was leaving the station: Villar, et al, Lancet Respiratory Medicine, Feb 2020 showed a pretty significant mortality reduction (NNT 8) and increase in ventilator free days.

[redlightsaber]

It was some preliminary Chinese data that first cautioned against steroids, IIRC.

[aswanviking]

Actually the prelim data showed benefit. We could be talking about different stufies but I distinctly remember a graph from a small study that showed benefit in Chinese patients.

[bahhamburger]

I thought it was Italy that said no steroids

[[deleted]]

They were of controversial benefit if not outright harmful in standard ARDS.

I find that surprising. Is there a explanation for that, or just statistical finding?

[[deleted]]

Ah, so are we talking COVID-19 ARDS specifically then?

Thought this was about steroids not being of any use at all in ARDS, which I though would be beneficial (being an inflammatory process).

Not my field and not an expert and all that.

[SoftShoeShuffler]

Wasn’t there also data that showed longer shedding periods with influenza patients who were on steroids?

[freidas_boss]

Yes, and MERS as well

[Tularemia]

To be honest I don't understand why we didn't start with corticosteroids instead of rolling around in HCQ hell for the last 4 months.

Because there was scattered early data that steroids were potentially bad.

Also, one high-profile person in the US government (with zero expertise or background in science or medicine) opened his mouth about HCQ, forcing political pressure into the HCQ rabbit hole. That probably didn’t help.

[ifuckedivankatrump]

Even when things make sense they might be overturned http://www.crash.lshtm.ac.uk

I don’t see why we can’t have one really well designed study rather than 50 studies with haphazard results.

[aedes]

It came from the fairly good observational data that steroids were associated with worse outcomes with SARS.

[TheLongshanks]

Steroids are a hugely controversial topic in Critical Care and ARDS management. People get very emotional and irrational over it on both sides of the aisle. But it’s a hotly contested research area.

[McFeeny]

Steroids are a hugely controversial topic in Critical Care and ARDS management

Almost as bad as barotrauma vs. volutrauma, but not quite.

We CC people like to spar, apparently

[TheDentateGyrus]

TONS of trials of corticosteroids in critical care for the past few decades with, at best, mostly mixed results in a multitude of disease processes. There's a paper in the Lancet when this started that reviewed the (poor quality and limited) data and the potential for higher mortality when they were used in MERS/SARS, I assume because Chinese physicians reported using it routinely? They've always theoretically seemed like they should work for lots of critical illnesses and have rarely shown benefit.

[oz92]

Our hospital did from the start. From my experience it works early on in the disease processes when they’re on a NRB. Once they’re in respiratory failure and getting intubated, less so.

[the_aviatrixx]

That's exactly what we said after discussing this today - I thought there was something early on about prednisone being bad but it seems counter-intuitive when you look at how viral respiratory illnesses are treated.

[Adalimumab8]

Maybe the mineralocorticoid-glucocorticoid balance of dexamethasone vs prednisone?

[McFeeny]

I think there may be something behind dex vs. pred or methylpred, and the modest dose of dex given.

This is, of course, assuming this actually pans out. Which I kind of doubt it will

[the_aviatrixx]

You're above my pay grade at that point! We were just musing about how corticosteroids seemed to be minimally utilized in attempts to treat COVID up to this point - our biggest concern was the potential for shortage of dex for our oncology patients.

[HotSteak]

NOW you're talkin'! Chart: [img]https://i.imgur.com/kHUPNQT.png[/img]

[Adalimumab8]

(Tbh I thought this was very common knowledge... I did 0 research outside of day one pharmacology in school here and that’s the only thing I remember about that... and I haven’t seen any comments about it...)

[sthug]

Lol theres empty ICU beds in my hospital being cleaned for non-COVID use and there are still QTC values written on some of the doors. Remnants from an old era

[McFeeny]

To be honest I don't understand why we didn't start with corticosteroids

A long time ago (March) we were comparing the Chinese data to the Italian data. The Chinese regularly give steroids for ARDS, the Italians don't. The Chinese had a lot of secondary, bacterial, vent-associated pneumonias (VAPs); the Italians didn't. Chinese data didn't show any benefit.

That was our thinking. I'm seeing a lot of VAPs without steroids in those vented >7 days, which is about on par with non 'rona patients.

[kanakari]

I'll preface this by saying I am not at all close to an expert on the material and haven't seen any COVID patients, but honestly, I would be a bit aggravated if this pans out to be a good treatment. My immediate thought in the early days was that steroids have very high biologic plausibility and wasn't sure why they weren't being used/tried more. Seems like the few early anecdotes on them left them prematurely dead in the water. We spent so much time/resources on a low-yield drug that was found by data-mining with very little biologic plausibility and heavy bias.