Let’s start with the basics. The coronavirus has infected over 8 million people worldwide. It has killed nearly 500,000 globally. In the United States, roughly 120,000 people have died. When the immune system overreacts and triggers a cytokine storm, it can be very hard to reverse. That’s why there was so much excitement about preliminary results from the RECOVERY Trial in the United Kingdom. The data on dexamethasone for COVID-19 look promising.
Results with Dexamethasone for COVID-19:
Investigators randomized patients with the coronavirus to receive either dexamethasone (by mouth or by injection) or usual care. This was a decent-sized study, with 2104 patients getting dexamethasone compared to 4,321 on usual care.
Patients who were really sick and on ventilators were one third less likely to die if they got dexamethasone. The investigators hypothesize that this powerful anti-inflammatory drug prevents an overreactive immune system from triggering cytokine storm.
Relative Risk Reduction vs. Absolute Risk Reduction:
Here’s the deal. People who were on oxygen with a mask or cannula had a 25% mortality rate if they were getting standard care. If they also got dexamethasone, the mortality dropped to 20%. That is to say, the absolute risk dropped by 5%. That’s a relative risk reduction of 20% and the number needed to treat (NNT) is 20. That means if 20 people on oxygen are treated with dexamethasone, one of them will survive who otherwise would not have done so.
When patients need to be on ventilators, they are even sicker. In this trial, 41% of those on ventilators died under standard care. Only 27% of those who got dexamethasone died while on ventilators. That’s an absolute risk reduction of 14%. The relative risk is 35% lower. The number needed to treat is an impressive 8. That means one person out of eight survives instead of dying if given dexamethasone.
People Not Needing Respiratory Help:
Hospitalized patients who did not need oxygen or mechanical ventilation did not benefit from dexamethasone. Standard care resulted in a 13% mortality rate for these patients. Dexamethasone, on the other hand, offered them a 16% mortality rate. This is not statistically significant, so no one is suggesting that the corticosteroid contributed to the extra deaths.
The full study has not yet been published and many experts are cautious about the initial enthusiasm. They point out that steroids like dexamethasone can suppress the immune response. Although it may calm the cytokine storm, it might also interfere with the body’s ability to fight off the virus.
Remdesivir vs. Dexamethasone for COVID-19:
A lot has been written about the antiviral drug remdesivir. It has received an Emergency Use Authorization from the FDA based on a placebo-controlled trial. How good was this injectable drug compared to dexamethasone? Remember, dexamethasone has a number needed to treat between 8 (if patients are on ventilators) and 20 if they are on oxygen alone.
Remdesivir has a number needed to treat (NNT) of 30. The drug is used differently, though. It needs to be given as early in hospitalization as possible because it slows viral replication. That means most people getting it won’t be on ventilators or even on oxygen.
In the NIH-sponsored trial that convinced the FDA to issue its EUA, remdesivir reduced patients’ time in the hospital by 31%, from 15 days to 11 days. Mortality was reduced to 8% instead of 11.6% among people on placebo.
We do not yet have a magic treatment for COVID-19. Dexamethasone is helpful only for the sickest patients. Remdesivir can only be used by hospitalized patients. We remain hopeful about an oral drug that is somewhat similar to remedesivir. It is called EIDD 2801. Researchers have begun clinical trials of this promising compound. Once we learn anything about their results, we will let you know.