COVID-19 TREATMENT PROTOCOL | IS DEXAMETHASONE EFFECTIVE?

There is an approved treatment protocol for established disease conditions. This protocol is evidence-based and carefully worked out to guide physicians and caregivers on decision-making about care in specific health systems and resource settings. The same goes for the coronavirus pandemic caused by the newly discovered SARS-CoV-2.

It has cost more than 431,000 lives globally. At this time, a lot is yet to be known about the disease; consequently, physicians and caregivers are still grappling with a formidable COVID-19 treatment protocol, drug, or vaccine.

On June 16, 2020, researchers at the University of Oxford announced that the first drug proven to reduce COVID-19 mortality had been identified. Dexamethasone, an inexpensive steroid is said to decrease the chances of patients with severe SARS-CoV-2 infection from dying by a third.

Dexamethasone is a widely available and efficacious addition to the constantly evolving COVID-19 treatment protocol.

According to the report, this drug is set to become the standard of care for the National Health Service (NHS) across Britain. The breakthrough with dexamethasone is remarkable as its trial produced striking results and can be used immediately to save lives worldwide, said Father Horby of Oxford University, a study leader.

Dexamethasone, a steroid, is an anti-inflammatory drug that helps dampen the excessive and potentially fatal immune response. Sadly, however, dexamethasone doesn’t help in mild cases (those without respiratory distress and who do not require mechanical ventilation) because suppressing their immune system will be counterproductive.

A few unproven regimens initially thought to be beneficial were dropped during randomized control trials. One of such is Chloroquine phosphate and Hydroxychloroquine sulfate as they showed no efficacy but had grave consequences.

What’s a COVID-19 treatment protocol?

  • Rest and support therapy
COVID-19 treatment protocol

During rest, the body troubleshoots and repairs itself from daily wear and tear. This pattern helps us relax, reduce stress, and improves overall function. During these times, it is important to maintain internal environment stability through sufficient caloric intake and monitoring water and electrolyte balance.

Other important pointers to observe during rest and support therapy include close monitoring of vital signs (pulse, respiration, temperature, and oxygen saturation).

  • Routine monitoring and investigations

For COVID-19, care is highly individualized. Monitoring blood routine results from urine routine analysis, C-reactive protein (CRP), biochemical pointers such as a liver enzyme, myocardial enzyme, renal function, etc., coagulation function, arterial blood gas analysis, chest imaging, and cytokines detection are all an integral part of care.

  • Oxygen therapy
COVID-19 treatment protocol

COVID-19 impairs the victim’s ability to maintain adequate ventilation. Therefore, the timely provision of oxygen is necessary in severe cases of SARS-CoV-2 infection. Usually, it includes the use of nasal catheter, mask oxygenation, and nasal high-flow oxygen therapy.

A small subset of patients might require mechanical ventilation to stay alive. Where applicable, inhalation of mixed hydrogen and oxygen (66.6% – 33.3%) can be employed; pure oxygen is toxic.

In severe cases, nasal cannulas or masks can be used to deliver oxygen straight into the lungs. Also important is a timely assessment of respiratory distress and/or hypoxemia as the condition can rapidly deteriorate.

When respiratory distress and/or hypoxemia of the patient cannot be eased with standard oxygen therapy, high-flow nasal cannula oxygen therapy or non-invasive ventilation can be employed. The patient’s condition can further deteriorate, say after 2 hours, then tracheal intubation and invasive mechanical ventilation can be considered at 6-8ml/kg of ideal body weight.

  • Antiviral drug therapy
COVID-19 treatment protocol

Remdesivir – An early in vitro study demonstrated that the antiviral activity of remdesivir is effective against the SARS-CoV-2 virus. Both the prophylactic and therapeutic version of the drug was found to improved pulmonary function by reducing the viral load in the lung of mice inflicted with a severe form of the infection.

Remdesivir has gained wide acceptance for sympathetic use round the world. Recently the Drug Controller General of India approved Remdesivir for “restricted emergency use” on severely ill hospitalized coronavirus patients.

Lopinavir/Ritonavir – this slightly reduced viral load without affecting other disease parameters. The therapeutic version of the drug improved pulmonary functions in the mice but did not reduce virus replication or severe lung pathology.

Alpha-interferon

In Wuhan, China, where the pandemic began, doctors used the drug interferon alfa-2b to treat some hospitalized patients. Researchers have reiterated that this class of long-used drugs also looks promising.

  • Antibiotic drug treatment

Inappropriate use of antibiotics is discouraged. Antibiotics can be coadministered to treat associated bacterial infection but not recommended where there is no indication – especially broad-spectrum antibiotics.

  • Use of steroids for COVID-19 treatment

Dexamethasone – is an over the counter drug, which invariably means you do not need a doctor’s prescription to purchase it. It is used in the treatment of many diseases such as arthritis and asthma. Some physicians also use dexamethasone to treat allergies and sometimes used in cancer management to suppress the nauseating results of chemotherapy.

The drug helps protect the body against self-destruction by suppressing its attack on its own cells. This also means it is an immunosuppressive drug. So, how then is this drug a wonder drug when it suppresses the body’s immunity?

Well, the simple reason is that during an infection, the body mobilizes an immune response to rid itself of the pathogen.

SARS-CoV-2 exerts its virulence primarily on the lungs. Consequently, the biochemical molecules (known as cytokines) summoned by the body are non-selective against infected cells, therefore, viciously attacks itself. This usually results in the patient needing mechanical ventilation to maintain oxygen saturation.

Is dexamethasone effective against covid-19 ?

As reported by the BBC, the results showed that administering low doses of dexamethasone to patients reduced mortality by one-third among those with the most severe cases of infection.

During the trial, a total of 2,104 patients were given dexamethasone and the result was compared with 4,321 patients who did not receive the drug. Thankfully, the inexpensive low dose dexamethasone reduced the number of death by one third in patients already on ventilators and by one-fifth in patients on oxygen support.

The data shown for patients on ventilators indicated that it reduced the risk of death from 40 percent to 28 percent. For patients with severe cases in need of oxygen,  the risk of death went from 25 percent to 20 percent. To a layperson, the difference doesn’t seem much, but clinically, it can make a huge difference when combined with other regimens like Remdesivir.

Researchers have carefully worked out an estimate that one out of every eight patients that’ll require treatment with mechanical ventilation in combination with this drug would prevent one death and then one in every 25 patients on oxygen alone without assisted breathing.

Overall, the trials show that dexamethasone when co-administered with other regimens and mechanical ventilation or oxygen is effective for treating a SARS-CoV-2 infection. The regimen is supported by Martin Landre, a professor at the University of Oxford, who is a co-head of the research.

What’s the cost of treatment with dexamethasone?

Dexamethasone is a simple, yet widely used everyday regimen. Known to be active as a long-acting steroid used in the treatment of ARDS and many other disabling medical conditions, it is also commonly taken to reduce inflammation.

Administration of dexamethasone has been seen to reduce the time of mechanical ventilation and consequently the overall mortality in moderate-to-severe ARDS patients.

The steroid helps prevent some of the damage that can occur when the body’s immune system is provoked into a cytokine storm in a bid to fight off pathogens.

Dexamethasone is low-cost. Globally, the average retail price of dexamethasone is less than $5. Following this, an improvement was seen in severe cases of COVID-19 when administered up to 10 days. Practically, that’ll put the overall cost at $ 50. Thankfully, the wonder drug is available globally, Martin Landre told the BBC.

Bottom line

Dexamethasone does not cure COVID-19, but, inadvertently saves the body from destroying itself through adverse immune response to the infection.

Dexamethasone might be a wonder drug but as with any pharmaceutical product, it could be dangerous if used unsupervised. Regimens with similar mechanisms of action should not be administered together. Using three or more antiviral drugs at the same time is not recommended; if an intolerable toxic side effect occurs, the respective drug should be discontinued.

For the treatment of pregnant women, factors such as the gestational age, drugs having the least impact on the fetus, as well as whether the pregnancy is terminated before treatment should be considered with patients being informed of these considerations.

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