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Business News/ News / World/  Trump’s covid-19 steroid treatment breaks from norm, doctors say
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Trump’s covid-19 steroid treatment breaks from norm, doctors say

wsj

Typically, the treatment would only be started when a patient’s blood-oxygen was persistently low

US President Donald Trump.Premium
US President Donald Trump.

Details of President Trump’s symptoms and treatment provided by his medical team suggest his condition is progressing along the course of other patients of his age and risk factors, but his doctors appear to be administering dexamethasone earlier in the course of treatment than they would with other patients, say physicians experienced in treating Covid-19.

“We’ve learned that he’s required oxygen, and that he’s had a fever and a cough," says Peter Chin-Hong, an infectious-disease specialist and professor of medicine at the University of California San Francisco “All those things in a 74-year-old who is slightly obese and male, makes me worry about him."

A patient in Mr. Trump’s shoes wouldn’t typically be released from the hospital on Monday, as the president’s medical team has suggested as a possibility, because of the way the disease can suddenly worsen and due to the monitoring requirements for the medications he’s receiving, Dr. Chin-Hong says.

However, the quality of medical care available in the White House—or whether it is comparable to the care the president would receive in the hospital—isn’t known, Dr. Chin-Hong said.

According to the White House, Mr. Trump was first diagnosed with Covid-19 on Thursday evening, and on Friday he received a dose of a monoclonal antibody cocktail, called REGN-COV2, made by Regeneron Pharmaceuticals Inc. In addition, Mr. Trump has been taking zinc, vitamin D, melatonin and daily aspirin.

Regeneron’s drug has shown encouraging early results in treating patients before they are hospitalized, but hasn’t been authorized for emergency use by regulators. Mr. Trump received the drug via a compassionate use request made by his medical team, according to the company.

The president’s physician, Sean Conley, said in a memo released late Friday that the president had also completed his first dose of remdesivir, an antiviral treatment made by Gilead Sciences Inc. that is cleared for emergency use in hospitalized patients with Covid-19.

A patient receiving remdesivir typically has their kidney and liver function monitored in case of side effects from the drug, which is usually done in a hospital, Dr. Chin-Hong says. The most common course of remdesivir treatment is five days for patients not on ventilators or life-support. In clinical studies, some patients were discharged from the hospital before completing the full course of therapy if their conditions had improved.

Because patients with Covid-19 can have their symptoms seesaw between stabilization and worsening, most doctors would be reluctant to release a patient similar to Mr. Trump from the hospital so soon, he says.

“I’ve seen a lot of patients linger in this plateau and then after seven days they fall of a cliff and crash," says Dr. Chin-Hong. “We’ve sent patients home and then they come back gasping for air in the emergency room."

Because of how varied Covid-19 symptoms and disease progression can be, it is difficult to generalize about treatment strategies for the president, says Michael G. Ison, professor of medicine at Northwestern University Feinberg School of Medicine. Adding to the difficulty is that Mr. Trump’s medical team hasn’t provided full, timely details about his care or symptoms, and at times the information they have provided has been contradictory, said Dr. Ison.

“Clinical care is looking at the patient in front of you, and every patient is different," Dr. Ison says.

On Sunday, Dr. Conley said that Mr. Trump had also started treatment with the steroid dexamethasone in response to two transient drops in Mr. Trump’s blood oxygen. The president received his first dose of dexamethasone on Saturday and would continue to receive it for the time being, Mr. Trump’s physicians said.

Typically, dexamethasone would only be started when a patient’s blood-oxygen was persistently low and requiring the need of supplemental oxygen because of the risks of causing harm in patients with less severe symptoms, says UCSF’s Dr. Chin-Hong. For instance, steroids suppress the immune system and can make patients more at risk of acquiring other infections, he said.

If Mr. Trump’s blood-oxygen levels haven’t required continuous oxygen support, his team by giving him the steroid could be treating him more aggressively than they would other patients. Dr. Chin-Hong called this more aggressive care “VIP syndrome," in which doctors might “give the VIP treatments earlier or out of sequence because you feel the urgency" to help a celebrity or politician recover.

Dr. Conley said at a press conference Sunday, “We debated whether we’d even start it, the dexamethasone, and we decided in this case the potential benefits early on in the course, probably outweighed any risks at this time."

The National Institutes of Health recommends administering dexamethasone in hospitalized patients who are receiving mechanical ventilation or who are receiving supplemental oxygen, such as via nasal tubes or face masks, for up to 10 days or until the patient is discharged from the hospital. The NIH treatment guidelines recommend against using dexamethasone in patients who are not receiving supplemental oxygen or mechanical ventilation.

Daniel Kuritzkes, chief of the Division of Infectious Diseases at the Brigham and Women’s Hospital said that one interpretation of a clinical trial of dexamethasone is that “the benefit of giving steroids in Covid-19 depends a lot on when in the course of the disease you give them," and that “they certainly don’t help and might be harmful in people who have no requirement for oxygen."

He said that there is not a concern that Regeneron’s drug could produce an adverse reaction when combined with other drugs. He said remdesivir and dexamethasone also don’t interact in a way that could be harmful.

“Assuming the president’s physicians are being guided by the state of the art evidence and consensus of the experts you would have to infer he must have had a significant oxygen requirement in order to warrant treating him with steroids," said Dr. Kuritzkes.

Dr. Kuritzkes noted an additional risk of steroids is that they make it tougher to control blood sugar and because of Mr. Trump’s obesity, he has a predisposition to insulin resistance and glucose intolerance. Dr. Kuritzkes said that while we don’t know if he has problems with blood sugar, the steroid could cause short-term problems.

“You wouldn’t want to be cavalier in the use of dexamethasone," Dr. Kuritzkes said.

Write to Joseph Walker at joseph.walker@wsj.com and Jared S. Hopkins at jared.hopkins@wsj.com

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