A steroid solution

Finding effective medical treatments for COVID-19 has been a slog, but researchers are finally making progress. Last year, U.K. researchers demonstrated that the steroid dexamethasone can help patients who have severe cases of COVID-19. Dexamethasone was ineffective in less severe stages of the disease, but scientific detective work has now identified a related steroid that can help prevent the worst cases.

Asthmatics were a clue to the discovery: We’d expect them to struggle against a respiratory bug, but instead, they fare better than average when fighting COVID-19. Doctors wondered: Could the inhaled steroids they use to manage their condition be the key?

To answer this question, researchers with the STOIC (Steroids in COVID-19) trial assessed a drug called budesonide, commonly prescribed to asthmatics under the trade name Pulmicort. The researchers asked whether giving this steroid within seven days of the onset of mild COVID-19 symptoms might prevent the disease from turning severe. (They defined prevention as avoiding a trip to the urgent care, ER, or hospital.)

The study results left little doubt: Of the roughly 70 patients who received the usual care, 10 worsened. Of the equivalent number on budesonide, only one did. Budesonide also made COVID-19 patients less likely to develop fever, and among those who did, it reduced the number of days with fever.

In short, the drug helps.

The news gets even better. Not only does budesonide help, but it’s cheap and common. As an “essential drug” the World Health Organization believes every country should make widely available, budesonide has helped generations of asthmatics keep their sensitive lung passages calm. It doesn’t last long in the body, so patients must take it twice a day, often for decades. That means the drug, whose patent expired in the late 1970s, is already in wide use.

Researchers measuring a medication’s effectiveness sometimes refer to a figure called the “number needed to treat,” or NNT—the number of patients, statistically speaking, who’d have to receive a given drug or treatment in order for one patient to benefit. For inhaled budesonide, the STOIC study’s authors calculated an NNT of 8. For every eight patients receiving the drug for mild COVID-19, the authors expected one patient to avoid worsening as a result.

Strong treatments normally have a much lower NNT—a drug that benefits every other patient, for example, has an NNT of 2. But the “usually mild, occasionally deadly” nature of COVID-19 may confuse the statistical analysis here. In the study, 6 out of 7 patients who didn’t get the drug still didn’t worsen, meaning the NNT could not have been less than 7. That’s not a surprise with this disease. The researchers’ analysis is sober, and resists the temptation to oversell the results.

Budesonide thus isn’t quite the “silver bullet” that its earliest promoters promised last summer, but it is now the first drug shown by quality research to prevent mild cases of COVID-19 from becoming severe or fatal cases.

The study, involving a team from the University of Oxford, is currently awaiting peer review. Still, Oxford’s lengthy track record of quality research argues strongly for believing it in the meantime. The evidence is certainly enough that if I were to develop symptoms, I would start taking budesonide myself.

One more question to address concerns the balance of accuracy and speed in the research world. The STOIC team originally expected its budesonide results by last September, yet even the online preprint article on MedRxiv wasn’t published until Feb. 8. Such delays are common, but having even a mediocre COVID-19 treatment last September might have saved many lives. We’ll discuss that delay problem in a future article.