Many doctors, including those in the United States, have been treating very ill COVID-19 patients with corticosteroids since the pandemic began. It makes biologic sense for those patients who have developed a hyper-immune response (a cytokine storm) to the viral infection. In these cases, it is the immune system’s overreaction that is damaging the lungs and other organs, and too often leading to death.
Dexamethasone and other corticosteroids (prednisone, methylprednisolone) are potent anti-inflammatory drugs. They are readily available and inexpensive.
The NIH COVID-19 treatment guidelines recommend the use of dexamethasone in certain people hospitalized with severe COVID-19. The recommendation was based on results from the RECOVERY trial. In the study, more than 6000 patients hospitalized with COVID-19 randomly received either dexamethasone or standard treatment. Patients who required supplemental oxygen or ventilators and who received dexamethasone were less likely to die within 28 days than those who received standard care. Dexamethasone did not have a benefit in patients who did not need respiratory support.
The FDA has granted emergency use authorization (EUA) for tocilizumab (Actemra) for the treatment of hospitalized adults and children ages 2 years and older who are receiving systemic corticosteroids such as dexamethasone, and who require supplemental oxygen, mechanical ventilation, or a heart-lung bypass machine, also known as extracorporeal membrane oxygenation (ECMO). Tocilizumab is a monoclonal antibody, already FDA-approved to treat several autoimmune diseases.
Some COVID patients get sicker because of an overreaction of the body’s immune response (a cytokine storm) to the viral infection. When this happens, the body overproduces interleukin-6 (IL-6) — a protein involved in inflammation — in lung cells. Tocilizumab blocks the action of IL-6, and thereby dampens the exaggerated immune system response.
The EUA was based on four clinical trials of hospitalized patients with COVID-19, which compared the use of tocilizumab plus routine care for COVID-19 (including corticosteroid therapy) to usual care alone. Through 28 days of follow up, tocilizumab plus usual care reduced the risk of death and the risk of being placed on a ventilator, and decreased the amount of time patients remained in the hospital, compared to usual care alone.
Tocilizumab is not authorized for use in non-hospitalized patients with COVID-19.
In October 2020, the FDA approved the antiviral drug remdesivir to treat COVID-19. The drug may be used to treat adults and children ages 12 and older and weighing at least 88 pounds, who have been hospitalized for COVID-19. Clinical trials suggest that in these patients, remdesivir may modestly speed up recovery time.
Baricitinib in combination with remdesivir
In November 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of baricitinib in combination with remdesivir in hospitalized adults and children two years and older who require respiratory support. However, there is not yet enough evidence to support the use of this therapy instead of dexamethasone with or without remdesivir.
Anticoagulation drugs (“blood thinners”)
Almost all people admitted to the hospital with COVID receive medications to help prevent blood clots. Doctors usually prescribe low dose heparin or enoxaparin. However, some patients require full doses of anticoagulants if they already have developed blood clots or have a high risk of doing so. Doctors always need to balance the risk of dangerous bleeding when prescribing full doses.