Dexamethasone may be ‘underused’ among critically ill patients with COVID-19
Dexamethasone, “an evidence-based treatment” for COVID-19, might have been “underused” among patients with the condition who required ventilation, researchers of a retrospective study wrote.
“There has been an enormous effort to find new or repurposed drugs for the treatment of COVID‐19,” Hemalkumar B. Mehta, PhD, an assistant professor of epidemiology at the Johns Hopkins School of Public Health, told Healio Primary Care. “However, it is unknown how these drugs are being used in the United States. Also, it is unknown if these drugs are used consistently across different health systems.”
Mehta and colleagues analyzed data on 137,870 adults hospitalized with confirmed or suspected COVID-19 between Feb. 1, 2020, and Feb. 28, 2021 (mean age, 59.4 years; 50.4% men; 47.8% non-Hispanic white). The data were gleaned from the National COVID Cohort Collaborative (N3C), which contains racial, ethnic and geographic information from a diverse group of more than 2 million patients with COVID-19 from 43 health systems across the United States.
Although the researchers called N3C the “largest cohort of patients with COVID-19 in the United States to date,” they acknowledged most of its data come from academic centers. Thus, their study “may not reflect the experiences of community hospitals.”
Mehta and colleagues wrote in Annals of Internal Medicine that during the entire study period, 6.3% of patients were administered hydroxychloroquine, 21.2% received remdesivir and 39.1% received dexamethasone. The use of hydroxychloroquine increased during March 2020, peaking at 42%, and started to fall by April 2020. Conversely, remdesivir and dexamethasone use slowly rose over the study period. Still, Mehta said that about 1 in 5 patients who may have benefited from dexamethasone did not receive it.
“Since dexamethasone is an inexpensive, widely available drug, we were surprised at its potential underuse among people who might have benefited from it,” Mehta said.
The RECOVERY trial, whose results came out about in mid-June, or about 4 months into Mehta and colleagues’ study, indicated dexamethasone decreased mortality by one-third in ventilated patients with COVID-19. According to the researchers, between 70% and 77% of mechanically ventilated patients were administered dexamethasone from July 2020 to February 2021. After other glucocorticoids were accounted for, the use of dexamethasone or other glucocorticoids varied from 78% to 84% across the study sites.
Mehta said he was glad to see the drugs in the study were used in ways consistent with the “emerging scientific evidence.” However, the potential underuse of dexamethasone and the inconsistent use of dexamethasone and remdesivir across the study sites warrants additional research.
“It is important to understand the basis for the potential underuse and variation that we describe,” he said. “We need to ensure that these drugs are given to the right patients and used consistently across health systems to improve outcomes among patients hospitalized with COVID‐19.”
In a related editorial, Marshall J. Glesby, MD, PhD, and Roy M. Gulick, both chiefs within the division of infectious diseases at the Weill Cornell Medical College, suggested the rate of dexamethasone or other glucocorticoids use may stem from several factors, including the “lack of definitive efficacy data” when these therapies were used for similar infections such as SARS and Middle East respiratory syndrome, and questions about the “generalizability” of the RECOVERY trial “given a higher mortality rate in the control group than in the United States overall.”
Glesby and Kulick also noted that the COVID-19 pandemic has dramatically changed and greatly accelerated how the medical community obtains information.
“Lessons learned from COVID-19 will improve how we assess and disseminate emerging data, leading to efficient implementation (or deimplementation) of evidence-based treatments,” they wrote.