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Dottoressa special: you can sign up now for a virtual book event! The New York Italian Cultural Institute’s presentation of my memoir, Dottoressa: An American Doctor in Rome, a reading in conversation with Alexander Stille that had to be cancelled in March, is going to be held via Zoom on Wednesday, July 1s, at 2:00 pm Eastern time. Click here to register.
Dexamethasone: On June 15th researchers for the British RECOVERY trial claimed in a press release that a cheap, familiar corticosteroid, dexamethasone, cut death rates in seriously ill COVID-19 patients by one-third. “Major breakthrough” “Fantastic” “Groundbreaking” Your resident cynic’s first reaction, like other scientists', was to advise caution – in part because these results seemed to turn previous thinking on its head. A large study of patients with rheumatic diseases and COVID-19 had found that those who were taking corticosteroids were much more likely to needhospitalization. And just a month ago an important meta-analysis concluded that “Corticosteroid use was associated with delayed virus clearing… There was no significant reduction in deaths... Hospitalization duration was prolonged and use of mechanical ventilation increased.” As the head of one of the United States’ best intensive care units commented, “We have been burned before . . . with exciting results that when we have access to the data are not as convincing.”
But we cynics were wrong this time, I think. Just a week later we were able to see those data in a preprint, and it does indeed look good. One excellent commentator explains how to make these results jibe with the many negative studies: the RECOVERY study found the sweet spot in terms of patient selection, dosage, and timing. In RECOVERY patients with milder disease, not in need of oxygen therapy, dexamethasone actually increased the risk of death. In patients who needed oxygen but could breathe on their own, the drug helped a little. In critically ill patients on a respirator, it helped a lot. After a little thought, these results make sense. In mild or early phases of this dastardly disease damage is caused by the virus actively multiplying in the body, and suppressing the immune system (as steroids do) will allow it to multiply faster. Late in the game it seems to be the body’s attempt to fight off the infection, the “cytokine storm” of an immune system in overdrive, that brings tissue destruction and death.
You should realize, though, that this study may not have a huge influence on the treatment of COVID-19 patients. Most intensivists already use corticosteroids as part of their last-ditch treatment of dying patients. One poll found that 54% of institutions already do just what the British authors suggest, giving corticosteroids routinely to all COVID-19 patients who require oxygen. And probably many more give steroids selectively to patients on oxygen, or routinely to all patients on respirators.
Hydroxychloroquine (Plaquenil): I thought it was going to finally be time to say Hasta La Vista hydroxychloroquine, now that the US Food and Drug Administration decertified it for COVID-19 treatment and both the National Institutes of Health and the World Health Organization cancelled their ongoing trials. …But no!!! You can’t kill the damn thing!!! Someone has brainwashed the reputable American Journal of Epidemiology into publishing a hydroxychloroquine promotional piece with the over-the-top title “Early Outpatient Treatment of Symptomatic, High-Risk Covid-19 Patients that Should be Ramped-Up Immediately as Key to the Pandemic Crisis.” This execrable piece of writing, which cites the same phony and borderline-mendacious publications I have been blasting in these pages for months, would be flunked in an undergrad epidemiology course. The AJE doesn’t allow for online comments, but they will be receiving an avalanche of outraged Letters to the Editor, including one from me.