Can Methylprednosolone or Dexamethasone be started in Mild COVID19 cases?
Q. Lot of discussion now going on for Judicious steroid use in patients with raised lab parameters by primary care physicians. It is argued that the main crux to prevent or reduce the later Cytokine Storm. Now off label physicians have started using it even as early as 3rd, 4th day thinking that if the patient is started on steroids under cover of antibiotics can prevent Covid pneumonia. The very fact that the CT Scan is positive on the 4th day. suggests that early steroids must be helpful. Unauthorised early use of anticoagulation especially aspirin 150 mg is now rampant thinking that if started early does a good job. It is being said that patients already on Aspirin and clopidogrel had lesser complications and early recovery.
CME INDIA discussed it on 22/8/20:
Dr Nishith Kumar, Pulmonologist, Ranchi: Regarding RECOVERY trial. The RCT clearly indicate that in patients with COVID-19 pneumonia, dexamethasone improves 28-day mortality in patients requiring supplemental oxygen or invasive mechanical ventilation. There was no benefit to patients not requiring oxygenation support and even a signal for harm. The reason behind Dexamethasone causing harm in patients who didn’t required supplemental oxygen can be varied. Most of these patients who have pneumonia but don’t require supplemental oxygen are in the viral phase of illness and immunosuppression will likely worsen disease in this phase…
CME INDIA Take home message:
In RECOVERY trial Dexamethasone 6mg (PO or IV) OD for up to 10d was used.
Higher dose of Dexamethasone May cause harm by inducing hyperglycaemia.
Dr Chandra asks: 81 yrs. old male patient with one day fever and paracetamol was started on day one. With fever still persisting and no other symptoms can steroids started along with Doxycycline and ivermectin. Is it safe to start steroids now? Can we get the Rapid antigens test / RT PCR done today for wait for two or three more days?
Dr N K Singh: I am not aware about such recommendation at GP level.
Dr Nishith: If patient needs oxygen, then only steroid beneficial is general consensus. Generally, Hypoxia is documented by Blood gases. Ecosprin is of limited use in OPD clinical COVID practice. Dabegatran or Rivaroxaban is of more value. There are two classes of antithrombotic drugs: anticoagulants and antiplatelet drugs.
Anticoagulants slow down clotting, thereby reducing fibrin formation and preventing clots from forming and growing. Antiplatelet agents prevent platelets from clumping and also prevent clots from forming and growing.
Anticoagulant
Dabegatran or Rivaroxaban
Antiplatelet
Aspirin or Clopidogrel
At present no role of steroid as of now in OPD patients who have normal SPO2 on Room Air. In fact it may cause more harm than benefit.
Dr Satish Kumar, Bokaro: In patients who are on Remdesivir, Dexamethasone should be replaced by Methyl-Prednisolone (IV 30-40 mg od) as Dexamethasone is likely to reduce the efficacy of Remdesivir.
May we use Dexamethasone with Remdesivir ?
https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103054
Dr Nishith Kumar, Pulmonologist, Ranchi: As per my understanding co-administration of Remdesivir & Dexamethasone has not been studied. As per literature clinically significant interaction is unlikely. Dexamethasone is a substrate of CYP3A4 and although remdesivir inhibits CYP3A4, due to remdesivir’s rapid clearance after i.v administration, remdesivir is unlikely to have a significant effect on dexamethasone exposure. Dexamethasone is unlikely to have a clinically significant effect on remdesivir as remdesivir has a moderate-high hepatic extraction ratio, and is used for a short duration in the treatment of COVID-19.
Dr BASAB Ghosh, Agartala: 👍 Aspirin? Statin?
Dr Nishith Kumar, Pulmonologist, Ranchi: Got to do review of literature sir regarding role of Aspirin/Statin. There are many ongoing clinical trials wr they are using Aspirin + Vit D. However, VTE prophylaxis in form of Enoxaparin 40mg s/c OD should be considered in all the patients who are hospitalised with COVID-19 unless & until there’s contraindication. Incidence of thromboembolism is very common in patients with raised D Dimer>2000. Consider therapeutic dosing in all such cases & try to get CTPA done wherever possible/feasible. Complications can happen even after discharge so consider NOACS in patients with D Dimer > 2000/established PE on CTPA.
Regarding choice of NOACS:
Apixaban is best in trials showing less bleeding.
Rest 2 (Dabigatran & Rivaroxaban) are noninferior. Advantage of dabigatran being less cost and antidote idracizumab available in case of bleeding…
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