Dexamethasone1 is a potent glucocorticoid steroid with minimal mineralocorticoid activity. Previously, it has been shown to be useful in treating acute exacerbation of multiple sclerosis, allergies, cerebral oedema, inflammation, and shock. Many geriatricians have branded dexamethasone as the ‘golden bullet’ in treating systemic discomfort in elderly populations.
In terms of its mechanism of action, it works by suppressing the migration of neutrophils and decreasing lymphocyte colony proliferation. As a result, dexamethasone increases serum vitamin A and prostaglandin level, and reduce the amount of certain cytokines (interleukin-1, interleukin-12, interleukin-18, tumour necrosis factor, interferon-gamma, and granulocyte-macrophage colony-stimulating factor).
Since the start of the COVID-19 pandemic, the official tally indicates more than 6.8 million have died from the disease2, the real number would be much higher than reported. Despite the huge amount of deaths globally, few effective therapeutics are available to hospitalized patients with COVID-193. The current recommendation3 is to use dexamethasone as the main therapy in hospitalized patients with COVID-19 who require supplemental oxygen, based on a previously published RECOVERY4 study. Recently, a large, national (US), multi-centre cohort study5 examined and detailed the clinical use of dexamethasone in hospitalized patients with COVID-19, which it further confirms the effectiveness of dexamethasone to treat COVID-19 patients.
The newly published national cohort study included 80 699 patients, among which 37 606 (46.6%) are women, 49 222(60.9%) identified as White, 13 230(16.4%) as Black, 20340(25.2%) as Hispanic, and 18247(22.6%) as other race. Of these patients, 13 040 (16.2%) did not require supplemental oxygen within 48 hours of admission, 56 368 (69.8%) required supplemental oxygen, 7618 (9.4%) required non-invasive positive pressure ventilation (NIPPV), and 3673 (4.6%) required mechanical ventilation (MV) and/or extracorporeal membrane oxygenation (ECMO). The eligible population was stratified into 4 cohorts: (1) no supplemental oxygen, (2) supplemental oxygen, (3) non-invasive positive pressure ventilation (NIPPV), and (4) MV and/or extracorporeal membrane oxygenation (ECMO). They were then randomly divided into two groups: starting dexamethasone within 48 hours of hospitalisation vs not starting any steroid within 48 hours of hospitalisation (control group).
After overlap weighting, all-cause inpatient mortality or discharge to hospice was lower for patients who received dexamethasone within 48 hours of either admission or escalation in oxygen support in the supplemental oxygen group (8092 patients [16.7%] vs 1748 patients [22.4%]) (Figure 1, panel B); and in the MV and/or ECMO group (1609 patients [60.5%] vs 586 patients [57.9%]) (Figure 1, panel D). In contrast, all-cause inpatient mortality or discharge to hospice was not lower for patients who received dexamethasone in the no supplemental oxygen group (543 patients [7.2%] vs 661 patients [12.0) (Figure 1, panel A) and in the NIPPV group (3420 patients [50.1%] vs 421 patients [53.2%]; aOR, 0.87; 95% CI, 0.73-1.04) (Figure 1, panel C).
The study5 concludes that early administration of dexamethasone was associated with improved mortality or discharge to hospice in those requiring supplemental oxygen or MV and/or ECMO. Continued research of patient subgroups will help inform and individualize treatment options for patients hospitalized for COVID-19.
Reference
- Johnson DB, Kelley B. Dexamethasone [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482130/
- WorldOMeter. Coronavirus toll update: Cases & deaths by country [Internet]. Worldometer. 2022. Available from: https://www.worldometers.info/coronavirus/
- Information on COVID-19 Treatment, Prevention and Research [Internet]. COVID-19 Treatment Guidelines. Available from: https://www.covid19treatmentguidelines.nih.gov
- The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report. New England Journal of Medicine. 2020 Jul 17;384(8):693–704.
- Mourad A, Thibault D, Holland TL, Yang S, Young AR, Arnold Egloff SA, et al. Dexamethasone for Inpatients With COVID-19 in a National Cohort. JAMA Network Open. 2023 Apr 17;6(4):e238516.
