US advisors add steroids to COVID-19 drug recommendations

The Infectious Diseases Society of America (IDSA) says generic steroids should be used to treat patients hospitalised with COVID-19.

The conditional recommendation is based on the results of the UK RECOVERY trial, which found that a low 6mg dose of dexamethasone reduced the chances of death by around a third in patients requiring mechanical ventilation, and 20% in those needing oxygen support.

The IDSA recommends that all patients hospitalised with severe COVID-19 should get oral or intravenous dexamethasone 6mg for 10 days, or if unavailable an equivalent corticosteroid such as methylprednisolone 32mg or prednisone 40mg.

The IDSA says patients who don’t require oxygen or ventilation shouldn’t be prescribed steroids, in line with the RECOVERY results which found no benefit in these patients.

Until now, the only drug recommended by the IDSA as a treatment for coronavirus infections was Gilead Sciences’ antiviral drug remdesivir, which wasn’t able to reduce mortality in the ACTT-1 study but was able to shorten the time to recovery from COVID-19.

Specifically, IDSA backs using Gilead’s drug in patients with severe COVID-19 on supplemental oxygen rather than in those on mechanical ventilation or extracorporeal mechanical oxygenation (ECMO) as the drug is still in limited supply.

In its guidance, IDSA notes that in the early days of the pandemic – based on earlier experience with the SARS and MERS-CoV coronavirus outbreaks – the use of corticosteroids was discouraged as it was thought they could stop the body clearing the virus and actually make the infection worse.

It seems that with SARS-CoV-2 – the coronavirus that causes COVID-19 – there is a much greater risk of runaway inflammation leading to acute respiratory distress syndrome that shifts the risk:benefit balance in favour of steroid therapy, according to the advisory body.

For now, IDSA doesn’t give any advice on combination use of dexamethasone with remdesivir, but the big advantage of generic steroids is that they are cheap and plentiful. They can also be given orally or intravenously while Gilead’s drug is IV only.

Gilead is providing remdesivir free-of-charge to healthcare systems at the moment, but is preparing to unveil its pricing and access strategy for the drug.

Last week, the influential Institute for Clinical and Economic Review (ICER) cut its recommended price range for remdesivir to $2,520 to $2,800 per course from its May assessment of $4,500 if dexamethasone becomes a standard treatment for COVID-19.