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Doctor speaks: Here is why random steroid use is making fight against COVID difficult in Kashmir

WhatsApp Image 2021 05 18 at 6.05.26 PM


Srinagar: Misinformation and misdiagnosis are posing a new challenge in the war against COVID.

Self-medication and steroid use coupled with anxiety are making the fight a little more difficult for both doctors and patients.

 

 Sample this: Qurat-ul-Ain, a 40-year-old diabetic from Srinagar city, began showing symptoms of mild COVID-19, with stable SPO2 levels and mild body ache. Yet, on the advice of a Whatsapp forward by a relative, she put herself on steroids, and stuck to it diligently for five days.

The result: her sugar levels spiraled to more than 500 mg/dl as against the normal of less than 140 mg/dl. Luckily, she survived to tell the tale, not without extensive insulin intervention therapy. Qurat, however, is not an exception. Several such cases have come to the fore, and doctors are warning against self-administration and indiscriminate use of steroids.

To understand these issues revolving around steroids, and separate facts from  a barrage of confusing social media posts, The Kashmir Monitor caught up with Dr Syed Mudasir Qadri, SKIMS Pulmonary and Internal Medicine Consultant.

How useful are steroids?

The recovery trial that came in June 2020, created the first window regarding the use of steroids (Dexamethasone) in COVID 19. One year down the line we have seen that apart from anticoagulants, steroids are the only drugs that have shown mortality and morbidity benefit in this disease.

Why should Steroids be administered carefully?

Steroids are double-edged swords, so we need to be very careful to initiate them, and once initiated (at the RIGHT TIME) our intention should be to give them in the RIGHT DOSE and for the RIGHT DURATION. Elevated sugars are seldom a contraindication for steroids and sugars can very well be controlled with insulin but a loss of lung function may be permanent.

I have come across many prescriptions wherein steroids that too Methylprednisolone (MPS) or Prednisolone (PS), have been prescribed from Day 1 of COVID illness and then either stopped or tapered at day 5. By this, they are actually precipitating the cytokine storm and pushing more patients from mild disease to moderate and severe disease. If there is a time for steroid use in the initial 10 days, it is usually after the 5th day. Till now there was only one hard indication for the use of steroids and that is hypoxia. But what is being noticed is that when hypoxia sets in (SPO2 less than 92%) a good portion of the lungs is already involved (damaged); the thinking should be to catch this as early as possible and save the lungs and minimize the lung damage.

When then should steroids be administered?

This second wave of the COVID 19 has surprised us all in many ways. There are some typical characteristics of the second COVID wave. We have noticed that there’s a group of patients who get “PERSISTENT FEVER”. Most of these patients ultimately land in respiratory failure due to moderate to severe lung involvement. If we check their inflammatory markers at 5-7th day most of these patients have high levels of markers and they respond very well to dexamethasone and most of these patients settle down with minimal or no lung involvement. I have actually been doing this and seeing excellent results. Of late I have come across many leading physicians and Pulmonologists across the country noticing similar findings, and persistent fever in the first week and have almost become a second indication of starting somebody on steroids (preferably dexamethasone).

What do consultants need to remember before starting a patient on steroids?

1. Steroids are given with two intentions.

A) TO COUNTER CYTOKINE STORM: (Dexamethasone or initial high dose (Pulse) of MPS for a few days, 3-5 days)

B) AS AN ANTI-INFLAMMATORY: for healing of widespread pneumonia and it needs to be given in the right dose and for the right duration. Otherwise, the patient may lose significant lung function due to POST COVID FIBROSIS.

2. In the initial 10 days, our main aim should be to catch as many patients as possible who qualify to be put on steroids (Preferably Dexa) and not let them go into moderate and severe disease later on. For that three things are very important:  Spo2, labs (Inflammatory markers), persistent fever

3. The dictum is to avoid steroids in the early phase (i.e. viral phase) as it may lead to increased viral replication and end up doing more damage than benefit. If ever steroids are to be started, should be done after the first 5 days

4. We cannot give a cocktail of steroids i.e. two types of steroids at the same time in the same patient. Yes, we may switch from one steroid to another e.g. if a patient on dexamethasone needs steroids even after the first 10 days (with moderate to severe lung damage), we may switch him to MPS or PS for the rest of the course of treatment.

5. The steroid of choice in the first 10 days should be dexamethasone only (with few exceptions e.g. when the patient has a stormy onset, severe hypoxia, very high cytokine levels)

6. After the first 10 days of dexamethasone, if somebody has a significant parenchymal involvement of the lungs (high CT severity of moderate to severe) a patient can be put on PS or MPS. But the dose and tapering is decided by the CLINICAL and RADIOLOGICAL response rather than blindly after the first or second week.

7. After the initial high dose pulse steroid therapy (usually MPS 125mg twice daily) for 3-5 days to suppress the cytokine storm, it is very important to scale down to the dose of PS or MPS required to treat the atypical viral pneumonia/organizing pneumonia, for which we need to continue the anti-inflammatory doses of the steroids (0.5-1.0mg/kg/day) for 4 to 6 weeks (in most cases) and taper after seeing acceptable clinical and radiological response. If we taper before that the chances of developing lung fibrosis are much more, and the patient may end up losing a lot of lung function and may become permanently oxygen-dependent.