Description: How steroids work in the Covid case

Dexamethasone is a corticosteroid commonly prescribed at Covid-19. AP

Last week, the World Health Organization (WHO) published new guidelines on the use of corticosteroids for the treatment of novels Coronavirus infection. Following the results of a meta-analysis that pooled data from eight randomized clinical trials, WHO made two recommendations: Use corticosteroid therapy for severe and critically ill patients for 7-10 days. thing COVID-19Do not use for non-severe Covid-19 patients.

What are Corticosteroids?

Corticosteroids are low-cost anti-inflammatory drugs that closely mimic cortisol, a hormone naturally produced by the human adrenal glands. They are commonly used in the treatment of rheumatic inflammatory conditions: muscle inflammation, vascular inflammation, chronic arthritis, lupus. They are used for lung disease, kidney inflammation, eye inflammation and to reduce swelling associated with brain and spinal tumors. The three commonly used corticosteroids are Dexamethasone, Hydrocortisone, methylprednisolone.

Earlier, Oxford researchers leading the RECOVERY clinical trial in the UK announced that dexamethasone in hospitalized Covid-19 patients with acute respiratory complications reduced deaths by up to a third. Since then, dexamethasone has become part of the standard clinical management protocol adopted by many countries.

What is the newly published meta-analysis?

The WHO Rapid Evidence Evaluation (REACT) Working Group of Covid-19 Therapy presented last week at JAMA a meta-analysis of systemic corticosteroid administration and association with mortality in critically ill patients with Covid-19. Seven trials were included in the final meta-analysis and patients were recruited from Australia, Brazil and Canada. China, Denmark, France, Ireland, Netherlands, New Zealand, Spain, United Kingdom, United States. A total of 1,703 patients were randomly assigned (678 for corticosteroids, 1025 for usual care or placebo).

The researchers classified trials based on low and high doses: low and high doses of dexamethasone, low doses of hydrocortisone, and high doses of methylprednisolone. The analysis sought to answer a key question: Is corticosteroid administration associated with reduced 28-day mortality in critically ill patients?

What are the results of your analysis?

In this study, 222 of 678 patients randomized to corticosteroids died, and 425 of 1,025 randomized to conventional treatment or placebo died. “This represents an absolute mortality risk of 32% for corticosteroids, compared to an estimated mortality risk of 40% for normal care,” it said.

The analysis found that corticosteroids were associated with “a reduction in mortality in critically ill patients who received or did not undergo invasive mechanical ventilation at randomization.” “…Trial results from diverse clinical and geographical settings suggest that corticosteroid therapy should be a component of standard treatment for critically ill patients with Covid-19 in the absence of compelling contraindications. They are doing,” it said.

“In a prospective meta-analysis of a clinical study of critically ill patients with Covid-19, administration of systemic corticosteroids compared to usual care or placebo was associated with a 28-day reduction in all-cause mortality,” he said. It was

What are the new WHO guidelines?

“We recommend systemic corticosteroids, rather than no systemic corticosteroids, for the treatment of patients with severe and significant COVID-19 (strong recommendation based on evidence of moderate certainty) WHO says.

WHO also contrasts with other therapies, which are “expensive and “difficult” because they acquire and require an “advanced healthcare infrastructure”, corticosteroids are “low-cost, manageable”. It’s easy and readily available around the world.” “Thus, systemic corticosteroids are one of the relatively few interventions in Covid-19 that could reduce inequality and improve health equity. These considerations are the strength of this recommendation. Has had an impact on.”

“Because of the ease of administration, the relatively short duration of the course of systemic corticosteroid therapy, and the generally benign safety profile of systemic corticosteroids, the panel received up to 7-10 days, so I concluded that it is highly effective.”

Another recommendation: “It is recommended not to use corticosteroids in the treatment of patients with non-severe Covid-19 (conditional recommendations, based on less certain evidence).”

The WHO said the second recommendation would apply to patients with “non-serious illness regardless of hospitalization status”. He specifically pointed out that patients admitted for isolation should not be treated with systemic corticosteroids.
“If patients with non-severe Covid-19 have worse clinical status (ie, signs of increased respiratory rate, dyspnea or hypoxemia), they should receive systemic corticosteroids,” WHO said. It was.

However, for non-severe Covid-19 patients who have already been treated with systemic corticosteroids for other reasons for chronic autoimmune disease and COPD, we recommend that the course should not be discontinued.

What are the research and recommendation limits?

The results of the meta-analysis are important because of the relatively large number of severe cases of Covid-19 from geographically diverse sites. However, the study reported that the optimal dose and duration of treatment could not be assessed analytically.

The WHO points out that the “long-term effects” of corticosteroids on Covid-19 survivor mortality are unknown. Second, he states that the clinical efficacy of corticosteroids in “non-severe” Covid-19 patients, ie, pneumonia without hypoxemia, remains “unknown”. Third, the immune effects of corticosteroids, and the risk of subsequent infections that may affect the risk of death after 28 days, remain uncertain.

What are India’s clinical management protocols for corticosteroids?

In June, the Government of India published revised guidelines on clinical management of Covid-19 patients, recommending dexamethasone as an alternative to another steroid (methylprednisolone) in moderate to severe cases. In a recently published FAQ on Covid-19 from AIIMS ICU, one question is whether methylprednisole is better than dexamethasone. Answer: “Corticosteroids are currently indicated for patients with moderate to severe Covid-19. Recovery studies use dexamethasone. However, depending on availability, use both IV dexamethasone or methylprednisolone.” I can do it.”

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