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Why steroids not recommended in Singapore treatment of COVID-19 patients despite 'major breakthrough' in UK

Dexamethasone is the first drug to improve survival in COVID-19 patients, a team from Oxford University found, and is widely available and inexpensive. But an expert in Singapore is urging caution.

Why steroids not recommended in Singapore treatment of COVID-19 patients despite 'major breakthrough' in UK

Dexamethasone, an inexpensive, on the shelf drug is being used to treat COVID-19 patients in the UK and parts of the US. (Photo: AFP/Justin Tallis)

SINGAPORE: Steroids are not routinely recommended in the care of COVID-19 patients in Singapore because they are known to cause harmful effects, a local expert has said. 

Dr Shawn Vasoo, clinical director at the National Centre for Infectious Diseases (NCID), was responding to queries from CNA after researchers from the University of Oxford found that the steroid dexamethasone was the first drug to significantly reduce the risk of death among severe COVID-19 cases.

The findings were hailed as a “major breakthrough” in the fight against the disease, with the inexpensive drug normally used to treat a range of allergic reactions, such as rheumatoid arthritis and asthma.

Daily doses of the anti-inflammatory steroid could prevent one in eight ventilated patient deaths and save one in 25 patients requiring oxygen only, the UK team found.

READ: Ebola drug remdesivir conditionally approved for COVID-19 treatment in Singapore

"Prior studies with reported benefits in COVID-19 have been non-randomised controlled studies and confounded by concurrent treatments," said Dr Vasoo. 

Historically, steroids have also been known to cause deleterious effects such as bacterial or fungal superinfection - a lesson drawn from the 2003 SARS outbreak, he added. 

"Steroids will also delay viral clearance and as such were recommended to be avoided unless there are other reasons for their use such as exacerbation of asthma, chronic obstructive lung disease and refractory septic shock in COVID-19 patients," Dr Vasoo told CNA.

Some COVID-19 patients in Singapore have received steroids due to other indications such as shock, low blood pressure or inflammatory conditions secondary to the disease, he said.   

File photo of an ampoule of Dexamethasone taken on Jun 17, 2020. (Photo: Reuters/Yves Herman) FILE PHOTO: An ampoule of Dexamethasone is seen during the coronavirus disease (COVID-19) outbreak in this picture illustration taken June 17, 2020. REUTERS/Yves Herman/File Photo

Until the recent “preliminary data” shared by the UK researchers, steroids have not been shown to have “specific benefits” in battling COVID-19 infection, Dr Vasoo said. 

“The evidence has been somewhat conflicting."

While steroids may “have a role” in select patients who are more ill with COVID-19, such as those on ventilators, doctors here are still “looking forward” to more detailed data so it can review the recommendations on using steroids for coronavirus patients.

“Dexamethasone is a commonly used drug, low cost and easy to administer. There will be further discussion on how this finding will influence and modify current treatment approach,” the clinical director said.

CNA has contacted the Ministry of Health (MOH) for more information.

READ: Singapore scientists discover 5 antibodies that can combat COVID-19, human trials to commence in coming months

DEXAMETHASONE GIVEN TO UK, US PATIENTS

The UK trial, carried out by the RECOVERY research group that is searching for effective COVID-19 treatments, administered the drug to more than 2,000 patients. The trial included a control group of 4,000 patients who did not receive the drug.

"Dexamethasone is the first drug to be shown to improve survival in COVID-19. This is an extremely welcome result," said Peter Horby, professor of Emerging Infectious Diseases in the Nuffield Department of Medicine, University of Oxford.

"Dexamethasone is inexpensive, on the shelf and can be used immediately to save lives worldwide."

Britain's Health Secretary Matt Hancock said the country's patients would start to receive the drug.

The trial results were described as being “particularly promising” as around 40 per cent of COVID-19 patients who require a ventilator end up dying, often because of the body's uncontrolled inflammatory response to the virus. For those receiving the new treatment, the mortality rate dropped to less than 30 per cent.

However, the UK trial showed dexamethasone to be ineffective in treating patients with milder forms of COVID-19.

READ: Commentary: The road to a COVID-19 vaccine is long and narrowing

Shortly after the UK trial results were released, the head of the World Health Organization’s (WHO) emergencies programme Mike Ryan warned that dexamethasone should be reserved only for serious cases in which it has been shown to provide benefits.

Doctors in some parts of the world, such as Denmark and the US, have started prescribing the steroid to COVID-19 patients.

But medical experts in other countries, including South Korea, Switzerland and Italy, have urged caution and asked for more results.

In the US, several hospitals faced with fresh surges of COVID-19 cases have started treating their sickest patients with dexamethasone.

The University of Florida’s Gainesville hospital updated its COVID-19 treatment guidelines as of last Tuesday to include using dexamethasone. It previously used the steroid sparingly for those patients.

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 Eduardo Oliveira, executive medical director for critical care for AdventHealth's central Florida region.

At its eight hospitals in the Orlando area, Dr Oliveira said the mortality rate for patients requiring ventilators was about 26 per cent, "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.

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Source: CNA/mi(hs)

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