New research released Wednesday seems to confirm one of the few hopeful discoveries made during the covid-19 pandemic: Cheap steroid drugs can save the lives of people with severe covid-19. The accumulating evidence has convinced the World Health Organization to embrace steroids as a standard treatment for these critical cases, though not for people with less serious illness.
The results of three new clinical trials were published Wednesday in the Journal of the American Medical Association (JAMA). All the trials looked at the effects of corticosteroids—a class of drugs long used in medicine to reduce inflammation and tamp down the immune system, among other things—on the prognosis of people with severe covid-19; one trial also looked at people diagnosed with moderate covid-19. Additionally, a group of experts assembled by the WHO published in JAMA a review of the evidence on steroids for critically ill people with covid-19, which reviewed two of these new trials as well as five others.
The WHO-led review included over 1,700 people with critical or severe covid-19 who were randomized into groups given standard care and either steroid treatment or a placebo. Though some individual trials found only weak evidence that steroids provided a life-saving benefit, the larger review found a clear association between steroid treatment and an increased chance of survival among critically ill covid-19 patients. Overall, it found that patients on placebo or usual care had about a 41% absolute risk of dying within 28 days, while those on steroids had a 33% absolute risk of dying. There was also no increased risk of serious adverse events associated with steroid treatment compared to placebo.
The findings affirm the earlier released results of a randomized trial by doctors in the UK, the RECOVERY trial, which found a life-saving effect from the steroid dexamethasone. But they don’t suggest that steroids are a miracle treatment for covid-19. Indeed, there’s some evidence that they can worsen the course of illness in people with only moderate covid-19, while they may be less effective for people with severe covid-19 who aren’t sick enough to need intensive mechanical ventilation.
But given the lack of other options for people at the highest immediate risk of dying, the affordability of these cheap, generic drugs, and the low risk of serious complications, the WHO is now advising their use as a standard treatment, given intravenously or via pill, for these hardest-to-save cases.
“We recommend systemic corticosteroids rather than no corticosteroids for the treatment of patients with severe and critical COVID-19,” the authors of a WHO “living guidance” report released Wednesday wrote. They also recommended against steroids for non-severe covid-19 cases, though with less certainty, given the limited evidence so far.
Steroids don’t directly treat the viral illness caused by the coronavirus. But a common complication of severe covid-19 is acute respiratory distress syndrome (ARDS), in which the lungs fill up with fluid and cut off the body’s oxygen supply. ARDS can lead to full-blown respiratory and/or multi-organ failure, which is routinely fatal. Another complication of covid-19 is sepsis, a severe bout of inflammation that attacks the whole body and can be life-threatening (sepsis can also trigger ARDS). Both conditions are characterized by an overactive immune response that turns against the body, which is why steroids may save people at the brink of death. That’s also probably why they’re less helpful or even harmful for people with less severe covid-19, since a strong immune response may still be needed to fend off the infection.
While many doctors across the world have likely already started using steroids widely for their covid-19 patients (in fact, several ongoing clinical trials of steroids were ended early after the RECOVERY trial was made public, due to fears they would be depriving some patients of clearly beneficial treatment), the guidance is sure to further enshrine steroids as part of the standard tool box for treatment. And it’s these incremental advances in treatment that should make handling the pandemic easier as time goes on.