Tuesday 16th June 2020
Figures for 15th June
UK COVID Deaths 38 / Total 41,736
James Cook Hospital – Total COVID deaths – 250
Two pieces of good news today. The first is that the RECOVERY research trial Investigators have issued a statement confirming that they have found that use of the drug dexamethasone reduces mortality in severely ill COVID-19 patients.
In the 2104 patients studied, dexamethasone reduced deaths by one third in ventilated patients and by one fifth in ward patients receiving oxygen. In ventilated ICU patients, the Number Needed to Treat (NNT) is approximately 8, meaning 8 patients would have to be treated with dexamethasone to prevent one death. In ward patients receiving oxygen, the NNT is approximately 25, meaning 25 patients would have to be treated with dexamethasone to prevent one death.
This single research paper has not been subjected to publication or peer review yet but most doctors will trust these preliminary results. Of all the proposed drugs being used to treat COVID-19, dexamethasone was the one that most of us thought could be effective. Dexamethasone is a corticosteroid, and modifies the body’s immune response and reduces inflammation. Other examples include the steroid prednisolone that people with asthma or COPD take when they suffer a flare-up of their condition. People with rheumatoid arthritis might take a corticosteroid to improve their joint inflammation.
Of all the treatments being investigated, this was the one that most of us thought would stand a good chance of being effective. We already use corticosteroids like dexamethasone in the ICU to treat severe bacterial septicaemia. It therefore isn’t a big leap to consider that these drugs may modify the inflammation cascade that occurs in COVID-19 and improve the chance of survival.
Interestingly, the initial advice coming out of China in the early days of the pandemic was that steroids were not effective in COVID-19 and indeed may cause harm. This may have been because the dose of steroid being used was significantly higher than the dose of dexamethasone used in the RECOVERY trial. Too much steroid causes immunosuppression and may well do more harm than good. Other side-effects include muscle weakness which is not desirable in recovering ICU patients.
So, whilst we await publication and review of the paper and further trial results that will add to this evidence, giving dexamethasone to COVID patients with respiratory failure seems the sensible thing to do.
The other drug that has proven to show benefit is the anti-viral drug remdesivir. This has been shown to shorten the duration of illness in coronavirus infection but has not yet shown any benefit on survival. In this regard, it’s a bit like Tamiflu which can be used to treat seasonal influenza. This drug again shortens the duration of the illness but doesn’t seem to affect mortality. Most doctors I know doubt whether the use of Tamiflu in hospital achieves anything and some of us are fearful that remdesivir may prove similar.
The one drug none of us believed would work was hydroxychloroquine. Yes, it’s used as an anti-inflammatory drug in conditions like rheumatoid arthritis but using it in an acute viral infection seemed dubious to a lot of us. Once Professor Trump endorsed it we knew for certain it was going to be rubbish. Unfortunately, it can also be quite dangerous in some critically ill patients. Not as dangerous as injecting bleach or disinfectant or swallowing a movie projector to ‘bring light inside the body’ but far from benign.
My second piece of good news concerns my friend Gary who is recovering from a prolonged ICU stay due to COVID-19 in a hospital in London. His physiotherapists have done sterling work and he is now able to walk about 100m with little or no help. He still has ongoing problems with swallowing and some nerve damage in his legs but he is looking stronger each time I see him via video call.
He had been waiting for a place at a neuro-rehabilitation hospital but there have been some logistical problems as that hospital closed temporarily at the start of the pandemic and is yet to re-open. As a result, ongoing rehabilitation will be arranged in the community with services that Gary can access locally or from home.
To be honest, I think this is for the best. I much prefer the idea of him being at home rather than moving to another hospital. Work is in hand to ensure that all these rehabilitation services will be ready before Gary is able to be discharged but he has told me that he could be ready for home at the end of this week or the beginning of the next. Good news indeed!