Use of Dexamethasone in Coronavirus disease (COVID-19)

On 2 September 2020, WHO issued an interim guideline on the use of dexamethasone and other corticosteroids for the treatment of COVID-19. The guidelines were developed by a panel of WHO and international experts and investigators and is based on evidence collected from seven clinical trials.

Dexamethasone is a corticosteroid used in a wide range of conditions for its anti-inflammatory and immunosuppressant effects.

It was tested in hospitalized patients with COVID-19 in the United Kingdom’s national clinical trial RECOVERY and was found to have benefits for critically ill patients.

According to preliminary findings shared with WHO (and now available as a preprint), for patients on ventilators, the treatment was shown to reduce mortality by about one third, and for patients requiring only oxygen, mortality was cut by about one fifth.

The guidelines make two recommendations:

Recommendation 1:

WHO strongly recommends that corticosteroids (i.e. dexamethasone, hydrocortisone or prednisone) be given orally or intravenously for the treatment of patients with severe and critical COVID-19.

Recommendation 2:

WHO advises against the use of corticosteroids in the treatment of patients with non-severe COVID-19, unless the patient is already taking this medication for another condition.

Time and duration of medication should be once daily for 7-10 days.

Daily dose should be 6 mg of dexamethasone, equivalent to 160 mg of hydrocortisone (i.e. 50 mg every 8 hours or 100 mg every 12 hours), 40 mg of prednisone, 32 mg of methylprednisolone (8 mg every 6 hours).

The panel of experts made its recommendation on the basis of the moderate certainty evidence of a mortality reduction of 8.7% and 6.7% in patients with COVID-19 who are critically or severely ill.

Dexamethasone has been on the WHO Model List of Essential Medicines (EML) since 1977 for several indications in multiple formulations. Since 2013, dexamethasone (Injectable formulation) has been indicated for respiratory distress syndrome in new-borns. Prednisolone is also on the EML and was included in 1984.

Dexamethasone and prednisolone are included on the EML for the following indications:

• allergic or hypersensitivity conditions, without further specifying the type
• pain and oedema due to malignancy in palliative care
• nausea and vomiting,
• as part of treatment protocols for some blood tissue cancers.

These indications are broad and can also include cytokine-related lung injury and as prevention or treatment of acute respiratory distress syndrome (ARDS) associated with severe acute respiratory infections (i.e. viral pneumonia). Both medicines are also recommended in children.