The news hit like a falling serac. Dexamethasone, a corticosteroid known for decades as a silver bullet among mountaineers and high-altitude rescuers, has been shown to do something no other drug has since the coronavirus pandemic began: revive infected patients on the verge of death.
A pair of medical researchers at Oxford University, Peter Horby and Martin Landray, issued a press release on Tuesday touting their clinical-study results, which claim that deaths among COVID-19 patients on ventilators could be reduced by a third and deaths among patients receiving oxygen without intubation could be cut by 20 percent if the patients were given dexamethasone, a.k.a. dex.
The story of the aptly named Recovery trial landed on the front page of The New York Times and in media outlets around the world. For months, frontline doctors have tried in vain to find a reliable treatment for the disease, which has infected more than eight million people and killed nearly 450,000. Suddenly, it seems there is hope.
Jeremy Windsor, a 48-year-old critical-care physician at Chesterfield Royal Hospital near Manchester, England, is among the hopeful. He has treated countless COVID-19 patients since March; nearly 300 people have died at his hospital from the disease. Windsor has also been a high-altitude mountaineer for more than two decades and summited Mount Everest in 2007, so he is well versed in the wide-ranging medical applications of dex, an inexpensive anti-inflammatory used in hospital settings to treat everything from brain tumors to asthma to septic shock.
Among mountaineers, dex is often taken preventatively—and controversially, since it raises ethical questions as a performance enhancer—to reduce brain swelling and improve one’s summit chances. National Park Service rescuers on Denali, in Alaska, use it to circumvent the slow process of acclimatization, and guides often wear doses of it around their neck or keep an injectable syringe full of it in their pocket in case a client stops moving due to cerebral edema.
“We’ve always thought that steroids have a very predictable and conventional use,” Windsor said by phone on Wednesday. “I’ve got to say, it surprised me to hear that dexamethasone had such a benefit in COVID-19 patients.”
The Recovery trial drew its subjects from hospitals across the United Kingdom, and Windsor and other physicians at Chesterfield supplied 150 of them. In all, more than 6,000 patients were randomized to receive dex (which they wouldn’t have gotten otherwise) or stick to standard treatments, like supplemental oxygen or ventilation, depending on the severity of their illness. About 2,100 of the patients were administered dex, but instead of receiving a dose three or four times a day, as dex is often given, they got it once a day for ten days, either by tablet or injection. “I wasn’t particularly optimistic about dexamethasone,” Windsor said. “When you look at previous coronaviruses, like SARS and MERS, steroids don’t seem to have played a big role in improving outcomes in those cases.”
The Recovery study showed no benefit among patients who did not require respiratory assistance, suggesting dex is only effective if someone’s lungs are in severe distress—a similar effect, albeit under different circumstances, to the way it has saved mountaineers in trouble high on a peak. Spanish-speaking guides call dex levanta muertos for the way it “brings life to a dead person,” Argentine Everest guide Damian Benegas once told me. When breathless COVID-19 patients who are on ventilators don’t improve, often their organs start to fail. But with dex—inexplicably, since no one knows exactly how it works—a significant percentage got better.
Still, despite the promising results and Tuesday’s media attention, there remains plenty of skepticism about whether dex really is a lifesaver, including among high-altitude doctors familiar with it. The Recovery study hasn’t gone through a peer review—a critical prerequisite to being published by one of the world’s major medical journals—but that will likely happen within the next couple of weeks. “The real challenge with this is the paper’s not out. All we really have is a press release from the study investigators,” said Andy Luks, a pulmonary and critical-care physician at the University of Washington’s Harborview Medical Center. “I actually think, despite all of the attention it’s gotten in the media, it’s too early to comment on whether this is going to have an effect on patient care.”
Luks, like Windsor, has plenty of experience with dex—he’s even taken it himself to aid his acclimatization on high-altitude ski tours in the Sierra Nevada and during medical missions in the Alps. He and his colleagues considered using it to treat COVID-19 patients early in the pandemic but opted not to, due to a lack of supporting data. He doesn’t think their decision will change until the study is published, if at all. “We’re starving for information about what really works for these patients,” he said, “but at the same time, you don’t want erroneous information out there to drive the discussion and, more importantly, treatments if it’s truly not a benefit.”
Peer reviews will examine the study’s data, methodology, and analysis—all of which have yet to be released—line by line. Any deficiencies could call into question the conclusion. “From a bias point of view,” Windsor said, “my big concern is we didn’t include everybody. We picked and chose who went into the trial, and we could withdraw patients if we thought the drug was detrimental partway through.”
Given the enormous public-health implications, doctors around the world will closely be following what happens next. Until then, the question of whether to administer dex rests with individual hospitals and very smart people with differing opinions. Be patient and remain cautious, or take a chance and possibly save a life?
“When we see something that reduces deaths by a third, that really does create flashing lights—it’s hard to ignore such an enormous difference,” Windsor said. “If you were to ask me tomorrow, when I’m working in the intensive care unit and someone comes in and needs ventilation, Would I use dexamethasone? I probably would. And I think our patients will come to expect it.”
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