Several U.S. hospitals in states with fresh surges of COVID-19 cases have started treating their sickest patients with dexamethasone rather than await confirmation of preliminary results of a study by British researchers, who said the inexpensive steroid saves lives.
The move illustrates how the pandemic is changing the way hospitals work, at least regarding COVID-19 patients.
Traditionally, doctors wait for detailed data to be published in a peer-reviewed journal - or for guidelines from medical societies - before embracing a new treatment, so they can better gauge the risks against the drug's benefits. The urgency of the coronavirus pandemic and lack of other treatments have altered those calculations.
Dexamethasone is the first drug shown to lower the risk of death in severely ill COVID-19 patients in what researchers running the trial hailed as a "major breakthrough."
The Oxford University researchers said in a news release that dexamethasone reduced death rates by around a third among COVID-19 patients requiring mechanical breathing assistance or oxygen. Britain's health ministry has already approved its use in the state-run health service.
"It almost feels unethical not to use the drug," said Dr. Kartik Cherabuddi, an infectious diseases specialist at the University of Florida's (UF) medical school.
UF's Gainesville hospital updated its COVID-19 treatment guidelines as of Tuesday to include using dexamethasone. It previously used the extremely cheap generic medicine sparingly for those patients.
Cherabuddi noted that his hospital - and many others - similarly started treating COVID-19 patients with Gilead Science's antiviral drug remdesivir based on data from a news release.
That drug, which unlike dexamethasone was not yet approved by regulators for any other conditions, shortened hospital recovery times in a clinical trial. It did not have an effect on mortality.
Several hospital systems, including New York's Northwell Health and the University of Washington (UW), had not been using steroids on COVID-19 patients as standard care - physicians had been prescribing it on a case-by-case basis. There was some concern it could lead to worse outcomes because it suppresses the immune system.
"For us, the case numbers are low and so there is not much pressure to do something new," said UW's Dr. Mark Wurfel, who is eager to see the final data. Places like Florida and Oklahoma, where COVID-19 hospitalizations are rising, are under more pressure, he said.
"The urgency of having hundreds, maybe thousands of very sick COVID patients in hospitals and ICUs changes the calculus. Many lives could be saved if the trial results are real," Wurfel added.
AdventHealth, which has nearly 50 hospitals in nine states, has been using dexamethasone for COVID-19 patients on ventilators with success since early April, said Dr. Eduardo Oliveira, executive medical director for critical care for AdventHealth's central Florida region.
At its eight hospitals in the Orlando area, Oliveira said the mortality rate for patients requiring ventilators was about 26%, "lower than almost every other reported mortality in the literature right now."
He noted it was difficult to know whether that success was due to the use of steroids.
After reviewing the British study release and trial protocols, Advent expanded its dexamethasone use to also include patients receiving supportive oxygen but not on ventilators.
Dr. Brent Brown, medical director of the University of Oklahoma's intensive care unit, said his hospital added the steroid to its treatment guidelines for patients in the ICU this week. Oklahoma is one of several U.S. states with rapidly rising coronavirus cases.
"We changed our practice completely. It was kind of an about-face," he said. "But we're delighted to have something that looks so promising."
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