COVID-19: The steroids that are helping seriously ill patients survive

Recently, we learnt that COVID-19 can be beaten. For the first time, there's an evidence-based treatment for this disease, and it’s a low-cost medicine that can be accessed in most places on the planet.

Four papers, published in the prestigious Journal of the American Medical Association (JAMA), confirmed earlier results from a UK trial showing that cheap, widely available steroid drugs help seriously ill patients survive COVID-19.

Based on the evidence, the World Health Organisation issued new treatment guidance, recommending steroids to treat severely and critically ill patients.

So, what does this mean?

Firstly – what are steroids? The word steroid is used here as shorthand for a class of hormones formally called corticosteroids or glucocorticoids. While related to, they're distinct from, the anabolic steroids used by bodybuilders, and sex hormones such as estrogen.

In fact, steroids are made normally in the body and are essential for life – in the right amount. Too much, and too little, can make you seriously ill. The right amount helps the body generate energy during stress and, pertinent to COVID-19, smooths peaks in immune system activity that could make you sick from excess inflammation during the response to infection. Think of it like a sprinkler system that detects too much heat and puts out cooling water in response.

The problem is, your ability to ramp up the production of steroids is capped – the adrenal glands, where steroids are made, weigh only a few grams, so when the immune system overactivity is too great, there isn’t enough "water" to put out the fire, and inflammation rages out of control.

It's abundantly clear now that the disease caused by the SARS-Cov-2 virus does its most damage through inflammation of the lungs, heart, and other organs that exceeds the ability of natural steroids to temper it.

Australian data included

So, if the problem is that the body can’t make enough, why not just give more? That is just what these and other trials have tested. One of the landmark JAMA studies included data on Australians.

In March 2020, the REMAP-CAP investigators, who include Professor Steve Webb and Victoria's Deputy Chief Health Officer, Allen Cheng, both from Monash University’s School of Public Health and Preventive Medicine, began randomising patients with COVID-19 to dosing strategies with the steroid hydrocortisone – importantly, comparing this with patients who received no steroid.

They stopped their trial when the larger UK “RECOVERY" trial reported its positive findings a few weeks ago, but regardless found a 93% probability that administration of steroids improved recovery for critically ill COVID-19 patients.

There have now been seven trials. As a JAMA editorial summarised:

 "Administration of steroids is clearly associated with benefit among critically ill patients with COVID-19, although the exact threshold at which an individual patient should be prescribed corticosteroids remains unclear."

If the universe is listening to our needs, allowing the first real proven treatment to be one the world can access cheaply is surely a good answer. But for anyone who thinks this means the worry is over, note this – even with an overall 33% improvement in mortality with steroids, 222 out of 678 in the combined analysis died. That is one-third.

The same editorial noted, with wording unusual for a scientific journal, that "the COVID-19 pandemic has brought fear and a sea of change to the world". This is a message about the very reasonable fear of this illness – but also of the hope that science, through hard work, global teams sharing their data, and sticking to rigorous methodology, will continue to show us safer paths to tread.