Finally, Light at the End of the Pandemic

[MediMike]

1 hour ago, Joelseff said:

There was a f/u article on remdesivir where a UCSF doc was quoted stating this conclusion was inappropriate since the study's end point was mortality reduction when the largest study was supporting remdesivir reducing hospitalization and convalescent times not mortality reduction. So remdesivir may not reduce (or will not reduce) mortality but will reduce convalescent times... I tried to find the article... I'll edit and post it when I find it.  

 

Edit found it! https://www.google.com/amp/s/www.sfchronicle.com/health/amp/Study-says-popular-COVID-drug-remdesivir-is-not-15654316.php

 

Here's a quote from the doc:

 

“Tell me something new because nobody has shown a mortality benefit with remdesivir,” Chin-Hong said. “The previous studies have shown decreased time to recovery, so people got better faster. I think it was on the order of 4 or 5 days, and that is pretty significant.”

 

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If they powered the study for that specific end point then there is nothing inappropriate about it. Think it's reasonable to assess for a mortality benefit.

The striking thing from the WHI study (from what it sounds like) is the lack of earlier symptom resolution or reduction in time for hospitalization.

I'm still throwing it at folks in the hope that it sticks, much more faith in my trust steroids though! (I've been team Annane for a long time)

We'll see when the actual peer review is published!

[Reality Check 2]

MediMike

Are you putting dexamethasone in nebulizers?

A Respiratory Therapist asked my permission years ago in the ER for a patient with very bad asthma.

I really liked the results.

Does it do any better than oral/IV?

Some local doctors are putting high risk but walking COVID patients on oral dex 6 mg TID for 5-7 days. I think they just pulled that out of an orifice but I think everyone feels the need to try something - keep folks out of the hospital or off supported breathing. 

I do not work first line with COVID folks - I do feel very lucky, by the way. I am very high risk myself.

Just curious what works best in your eyes so far with the walking wounded or on the verge of hospital/resp support.

Thanks

 

[GetMeOuttaThisMess]

Hope that they aren't expecting immediate improvement.  Onset of action is in hours, not minutes.

[Boatswain2PA]

2 minutes ago, GetMeOuttaThisMess said:

Hope that they aren't expecting immediate improvement.  Onset of action is in hours, not minutes.

Yeah, my understanding is same efficacy, time of effect, and duration no matter what the route.

[Cideous]

1 hour ago, Reality Check 2 said:

MediMike

Are you putting dexamethasone in nebulizers?

A Respiratory Therapist asked my permission years ago in the ER for a patient with very bad asthma.

I really liked the results.

Does it do any better than oral/IV?

Some local doctors are putting high risk but walking COVID patients on oral dex 6 mg TID for 5-7 days. I think they just pulled that out of an orifice but I think everyone feels the need to try something - keep folks out of the hospital or off supported breathing. 

I do not work first line with COVID folks - I do feel very lucky, by the way. I am very high risk myself.

Just curious what works best in your eyes so far with the walking wounded or on the verge of hospital/resp support.

Thanks

 

I've been putting Dex in nebs for years.  Really worked great for RAD exacerbations.

[MediMike]

2 hours ago, Reality Check 2 said:

MediMike

Are you putting dexamethasone in nebulizers?

A Respiratory Therapist asked my permission years ago in the ER for a patient with very bad asthma.

I really liked the results.

Does it do any better than oral/IV?

Some local doctors are putting high risk but walking COVID patients on oral dex 6 mg TID for 5-7 days. I think they just pulled that out of an orifice but I think everyone feels the need to try something - keep folks out of the hospital or off supported breathing. 

I do not work first line with COVID folks - I do feel very lucky, by the way. I am very high risk myself.

Just curious what works best in your eyes so far with the walking wounded or on the verge of hospital/resp support.

Thanks

 

By the time they reach me they're breathing through plastic, but depending on the hospitalist I'll get consulted for "COVID Management".

Reading the RECOVERY trial what you see is modest benefit for those on oxygen and pretty great benefit when you're on mechanical ventilation. There was no benefit in patients who didn't require oxygen with an actual trend towards harm, so I don't recommend it.

In the setting of acute reactive airway dz with underlying COPD I personally lean towards budesonide as my ICS of choice, with asthma the evidence is more for systemic via oral or IV routes. I'd have to dig but I think inhaled steroids for asthma showed little to no efficacy in multiple trials...I think.

With all that being said, if it's a patient you would normally prescribe a course of dex to for RAD then don't deviate from your practice (my wife and I had a fight about this), but I wouldn't start it for a patient simply because they are COVID+.

There just aren't any data supporting any therapies other than symptom based management in the ambulatory patient. Cough suppressants, staying hydrated, APAP etc. Our normal viral stuff

Edit: Just saw the tid part of your colleagues' dosing regimen. I have no idea where that came from. "COVID Dosing" is 6mg qd x10

Edited October 18, 2020 by MediMike