ROHIT, 28, is a healthy man. When I first spoke to him, it was the sixth day of his symptoms. He sounded short-winded. His oxygen level (SpO2) was 97 per cent. After mild exertion, it dropped to 94 per cent. He may have already developed lung damage.
The second wave has hit India like a tsunami. Beds, medical oxygen and mechanical respiratory support are in short supply. We must aim to rescue patients before they require any of these scarce health care resources. But, is it possible?
Majority of SARS-CoV2 infections self-resolve with just supportive medications like paracetamol and adequate rest. It is only a minority which progress into a stage where they require hospitalisation. There are only two effective treatment options that have proven beneficial in reducing chances of death from Covid-19—steroids and tocilizumab.
The SARS-CoV2 infection is characterised by an initial viraemic phase where there is viral replication and shedding, followed by a hyper-inflammatory phase, which is the response of the body’s immune system against the virus particles. The latter phase, usually, starts after around five to seven days from onset of symptoms. If left unchecked, the hyper-inflammatory lung damage can create havoc in the body and cause irreversible lung damage. It is usually manifested as hypoxia (inability to maintain oxygenation in the blood stream). Steroids are easily available, and are low-cost medications that help extinguish the inflammatory firestorm.
In order to test whether steroids help patients, a large clinical trial was conducted among patients who were hospitalised. Patients who required oxygen or respiratory support benefited from the steroids, whereas those who did not require oxygen did not show a benefit with the use of steroids. Hence, most guidelines have not incorporated the use of steroids unless patients require oxygen support (SpO2 < 92 per cent). However, on careful reading, it can be noted that a significant number of patients in the recovery trial were started on steroids even before the viraemic phase was over (as early as three days from onset of symptoms). More than half of the trial participants had diabetes, heart diseases or lung diseases. Clearly, using steroids that early in the disease course is harmful, especially for patients who are already suffering from multiple illnesses. But, in these critical times, we must act with the available evidence.
Anecdotal evidence suggests that using steroids at the right time for the right patient would thwart the hyper-inflammatory phase and help reduce the chance for requiring respiratory support. But who is the right patient and when is the right time?
Any patient who experiences worsening lung symptoms such as shortness of breath, cough, or a consistently dropping trend in SpO2 level over few days or a drop in SpO2 level, with or without high grade fevers, any time after the initial five to seven days of onset of symptoms should be considered for an empiric treatment with steroids under medical supervision. Ideally, it is best to do a low dose CT scan of the chest or an X-ray to confirm the lung damage. Steroids should not be started within five days of onset of symptoms or as a preventive therapy. It should not be used in mild illness, where none of these symptoms or signs are present. Patients should not self-medicate themselves with steroids.
Of the 2,100 participants who got steroids, two had high blood sugars, one had gastric bleeding and one had delirium. So, ensure good control of blood sugars and consider gastric protective therapy. The fungal disease—mucormycosis—is an extremely rare complication of patients on immunosuppressive therapy for prolonged duration, and is not seen with a short course therapy as used in the recovery trial. Steroids are potentially life-saving therapy in Covid-19 for hospitalised patients who are on respiratory support. If a patient like Rohit had followed the widely used home care guidelines from government and volunteer organisations, he would have waited until his SpO2 dropped to less than 92 per cent before he sought help. I treated him with steroids. Rohit fully recovered within a week. He did not require high-level respiratory support.
Dr Mathew is a Cambridge-trained epidemiologist, and American Board-certified medical oncologist, haematologist and internist practising in Kochi. He has experience in providing home care services for patients with Covid-19.