Trump Is Being Given Dexamethazone, Usually Reserved For Extreme Covid Cases

This suggests that Trump's virus is more serious than the public has been led to believe. JL

Andrew Joseph reports in Stat:

President Trump has started receiving dexamethasone, a steroid that has been shown to be helpful in people with severe cases of the disease but that doctors warn should not be used early in the course of the illness. The National Institutes of Health’s treatment guidelines for Covid-19 say dexamethasone should be used only in hospitalized patients who are on ventilators or who require supplemental oxygen, and specifically “recommends against using dexamethasone for the treatment of Covid-19 in patients who do not require supplemental oxygen.”

To treat his Covid-19, President Trump has started receiving dexamethasone, a common steroid that has been shown to be helpful in people with severe cases of the disease but that doctors warn should not be used early in the course of the illness.

The announcement from Trump’s medical team Sunday morning that the president is on dexamethasone is sure to increase speculation about the president’s illness and was at odds with the generally upbeat description of his condition provided by his physicians. His doctors said Trump had not had a fever since Friday morning and did not have any shortness of breath. One even said that, if Trump “continues to feel and look as well as he does today,” their goal was for him to return to the White House on Monday.

Dexamethasone is generally reserved for patients who have serious disease. The National Institutes of Health’s treatment guidelines for Covid-19 say dexamethasone should be used only in hospitalized patients who are on ventilators or who require supplemental oxygen, and specifically “recommends against using dexamethasone for the treatment of Covid-19 in patients who do not require supplemental oxygen.”

Trump’s doctors confirmed that the president received oxygen for about an hour on Friday after a temporary drop in his oxygen levels — something they danced around saying during a Saturday briefing. Sean Conley, the president’s physician, told reporters on Sunday outside Walter Reed National Military Medical, where Trump is being treated, that the president also experienced a “transient” drop in oxygen levels Saturday but said that he wasn’t sure if oxygen was given.

Conley said that drop in Trump’s oxygen saturation to 93% on Saturday morning prompted the decision to initiate the steroid therapy, believing “the potential benefits early on in the course” outweighed any downsides.

“Our plan is to continue that for the time being,” Brian Garibaldi, another of Trump’s doctors, said about the dexamethasone.

Ethan Weiss, a cardiologist at the University of California, San Francisco, who went to New York to treat critically ill Covid-19 patients during the city’s surge, told STAT, “Nothing matches up.” Weiss said that Trump’s medical team had “an impossible job,” but that “you can’t say he’s fine and he’s going home tomorrow and by the way he’s getting dexamethasone, which was shown in [a clinical trial] to be helpful in only the sickest patients.”

The concern with dexamethasone is that it can suppress the immune system’s activity broadly. While that can be helpful in severe illness — which is typically caused by the immune system overreacting to the infection, not the virus itself — giving the steroid too soon could hinder the immune system from fighting the virus in the first place.

“You don’t want to give it to a patient too early,” Nahid Bhadelia, the medical director of Boston Medical Center’s Special Pathogens Unit, told STAT Friday about dexamethasone. “It’s a blunt instrument, so it may suppress a good immune response as well as a bad one.”

In a clinical trial, dexamethasone reduced deaths by a third in patients hospitalized with Covid-19, but the benefit differed depending how sick patients were. In patients not receiving supplemental oxygen, the study showed no benefit and potential harm.

“Those patients who were not requiring oxygen actually had a statistical trend toward worse outcomes — the dexamethasone was only beneficial in patients who were requiring oxygen,” said C. Michael Gibson, a professor of medicine at Harvard Medical School. He also noted that the effect for dexamethasone was only seen in patients who had been sick for longer than seven days. Trump started feeling sick Thursday, his doctors have said.

Trump is also in the middle of a five-day course of the intravenous antiviral remdesivir. His doctors said the president could continue receiving the infusions at the White House if he were discharged from Walter Reed.

Overall, Trump’s medical team continued to portray Trump in good spirits and relatively good health. But as during a Saturday press briefing, Conley answered questions about certain aspects of Trump’s condition vaguely. He was asked several times about potential damage to the president’s lungs and said “there are some expected findings” without giving additional details.

Conley was also asked why he had avoided saying during the Saturday briefing whether Trump had ever been given supplemental oxygen.

“I was trying to reflect the upbeat attitude the team, the president through his course of illness has had,” Conley said. “I didn’t want to give any information that might steer the course of illness in another direction, and in doing so it came off that we were trying to hide something, which wasn’t necessarily true.”