13 February 2021 | New Scientist | 45people hospitalised with covid-19 came
last summer in the form of a cheap, readily
available steroid first used for rheumatoid
arthritis: dexamethasone.
It quickly became clear that what often
killed patients wasn’t the virus itself, but
the body’s own immune system trying to
fight off the infection. For some people with
the coronavirus, an out-of-control immune
response could cause deadly collateral damage
to the lungs, heart, blood vessels, kidneys and
brain. Much of the search for drugs has focused
on compounds that might help tamp down
this overblown response.
Early on, doctors tried medicines already
approved to treat autoimmune disorders.
Disappointingly, early clinical trials showed no
benefit. Then in July 2020, the RECOVERY Trial
at the University of Oxford posted results for
the anti-inflammatory dexamethasone. Many
immune modulators are precise, switching
off specific parts of the immune response.
Dexamethasone is a much blunter weapon –
more a sledgehammer than a chisel, says
Kaplan. But the study found that hospitalised
covid-19 patients needing supplementary
oxygen or invasive ventilation who also
received low-dose dexamethasone were
one-third less likely to die.
“It really did completely change everything,”
says Martin Landray, an epidemiologist at the
University of Oxford and co-director of the
RECOVERY Trial. “We announced the results
at lunchtime, it was NHS policy by teatime,
and it was saving lives by the weekend.”Carrie Arnold is a writer based in
Virginia. Follow her @edibitesThe drug is also cheap and readily available,
meaning that nearly every hospitalised
covid-19 patient who needs help breathing
in most high and middle-income countries
is routinely given dexamethasone.
To a casual observer, it might seem that not
much of significance has changed in the way
hospitals treat covid-19 patients. Far from it,
says Simonds. Over time, the cumulative
effects of these three changes – and a variety
of other small, subtle shifts in patient care –
have helped reduce mortality in hospitalised
covid-19 patients by about one-quarter. And
many of these improvements are within reach
for much of the global community. A course of
dexamethasone is cheap and widely available,
as are nasal cannulas. Prone positioning is free.
Now the goal is to help these standards
continue to evolve as we learn more, says Janet
Diaz at the World Health Organization. The
sheer volume of clinical trials that emerged in
the wake of covid-19 have made it challenging
at times to sift the high-quality data from the
rest. That makes it really difficult to make
many definitive statements, says Clifford Lane
at the US National Institute of Allergy and
Infectious Disease. For now, physicians still
rely on clinical judgement and educated
guesses far more than he would like. ❚ALAINJO
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AGESpatients, who have no other option
(see “The view from intensive care”, page 43).
A second major change was born of
desperation. Intensive care specialists had long
known that placing sedated, ventilated people
face down in the prone position makes it easier
for oxygen to reach more of the lungs. Early in
the pandemic, in places like Milan there simply
weren’t enough ventilators to go around. With
no other options, doctors had people lie on
their stomachs. This “awake proning” hadn’t
really been done before, and certainly not as
a matter of routine.
Buying time
A similar scenario played out at hospitals
around the world. At the height of New York’s
surge in early April, doctors at Columbia
University had eight patients who needed
mechanical ventilators simultaneously, but
only enough staff to do one patient at a time.
To buy precious minutes, they placed three
patients in the prone position. An hour later,
all three saw their breathing improve so much
they no longer needed ventilators. Within
days, the doctors launched a clinical trial,
and other universities followed suit. Studies
showed that prone positioning helped keep
hospitalised patients on non-invasive
ventilation from getting sicker and needing
to be admitted into intensive care. It isn’t just
drugs that have saved lives, says Simonds.
That said, one drug has been a game
changer. The third major alteration to care for
“ We announced the
results at lunchtime,
it was policy by teatime,
and it was saving lives
by the weekend”
Using more methods
to provide oxygen
reserves ventilators
(left) for the sickest