He was a very pleasant and healthy 42 year old guy. He was a bit overweight and had mild diabetes, but otherwise had no real problems. He had plans to get married in just a few months to his long time girlfriend. Then the coronavirus hit the nation . Then it hit him. He got sick in the beginning of May but had it not so bad at first. He had a mild cough, aches, and fatigue but he wasn’t completely incapacitated. It was nothing like the horror stories he had seen on TV.
Then, one morning he woke up and something was different. He had a high fever and felt terrible, much worse than the previous few days. It was the fact that he was a little short of breath that was most concerning. Being engaged to a nurse meant that ignoring the symptoms was not an option and he was convinced to go to the ER under a bit of relationship duress. He got the usual workup – x-ray, blood tests, vital signs. The ER doc thought about sending him home because he looked so good but his oxygen was a bit lower than normal so, she thought the better of it and he was admitted under observation.
The first night wasn’t so bad, but the next morning something changed. He felt much worse. He had high fevers and was struggling to breathe a bit more than the day before. His oxygen needed to be increased.
Over the next several hours he deteriorated rapidly. He went from needing a small amount of oxygen to needing a high flow oxygen system with 100% oxygen. He came to my ICU with an oxygen saturation in the low 80s on 100% oxygen. He was breathing too rapidly to complete full sentences. I was worried I would have to put him on the ventilator.
I started him on the combination of interventions I have been using since the beginning of the pandemic (You can read about it in my post Good news from the front lines). One of the treatments I gave him was a medication called dexamethasone.
It’s as if the virus cuts the brake lines to the immune system as its rolling down a hill
The rationale for this treatment comes from observations of how the disease progresses in the severe cases. In people who get severe COVID-19, there is a point of transition where they go from being just a bit sick to seriously ill in a relatively short time. They develop respiratory failure with extremely low oxygen levels and eventually failure of other organs as well. The immune system will go into overdrive leading to uncontrolled inflammation. This has been referred to as a hyperinflammatory phase or a “cytokine storm” (cytokines are the molecules that act as the messengers for the immune system). It’s as if the virus cuts the brake lines to the immune system as its rolling down a hill.
Dexamethasone is a synthetic version of a steroid hormone that has many effects on the body and has been used for decades for multiple conditions. One of the things it does is broadly and generally suppress the immune system and inflammation. This was initially thought to not be a good idea in COVID-19 because you need the immune system to fight the virus. Further there was evidence from other viruses that steroid medications like dexamethasone could prolong the time that the virus was in the blood. This led to some controversy about its use in COVID-19.
Many physicians, like me, however were seeing individuals suddenly transition from just being sick to nearly dying in a short period of time – too short a time to be explained by the direct effects of the virus alone. We were seeing blood tests that are associated with uncontrolled inflammation suddenly skyrocket and people were getting high fevers indicating an inflammatory response. Since it seemed that the inflammation was the problem, not the direct viral damage, we felt the benefits outweighed the risks. I certainly received quite a bit of backlash from other physicians ,but I felt it was the right thing to do.
Fortunately, there was ongoing research that has now been publicly reported ahead of its upcoming publication. There was a trial in England called the RECOVERY trial. This was a trial evaluating a number of different therapies for COVID-19. One of them was dexamethasone. The results were very exciting. They found that Dexamethasone reduced deaths by one-third in patients on ventilators and by one fifth in patients receiving oxygen only.
Dexamethasone is now the first drug to be shown to improve survival in COVID-19
This is huge because dexamethasone is now the first drug to be shown to improve survival in COVID-19. It didn’t just shorten the length of time in the hospital or with symptoms. It actually meaningfully saved lives.
The beauty of this is that dexamethasone is an old, cheap, widely available drug. Everyone in the first to the third world has access and all doctors are comfortable with its use and side effect profile. There was no pharma influence on the trial and no cats are getting fatter because of this. Unlike other drugs which were all about social media hype (e.g. hydroxychloroquine) or pharma hype (e.g. tocilizumab and remdesivir), this drug was based on sound rationale and well designed science.
One small caveat is that dexamethasone did not help people who did not require oxygen. This makes sense because they have not yet transitioned to the hyperinflammatory state. This means it is not something to take if you sick with coronavirus at home. At this point in the disease the effects on blunting the immune response may even be harmful.
I did not need to put my patient above on the ventilator. After 48 hours of dexamethasone along with the other therapies he went from 100% oxygen down to just a few liters per minute through a small nasal cannula. He was discharged home a few days later on no oxygen at all. Thanks to dexamethasone, he can now look forward to a wedding instead of a funeral.