COVID-19: How steroids were an unnecessary burden during the second wave

This is the first of a three-part series. Click to read the second and the third parts.

Ajit, a 45-year-old graphics designer in New Delhi, tested positive for the novel coronavirus (SARS-CoV-2) in mid-April, when the country was in the grip of a devastating second wave of the novel coronavirus (COVID-19) pandemic.

“Though my symptoms were mild, I reached out to a doctor as I wanted to cover my bases,” he said. The doctor, too, wanted to ensure that Ajit’s health condition did not deteriorate at a time when hospitals were full and promptly prescribed him steroids with a cocktail of antibiotics and antivirals.

Three months later, Ajit and his doctors are painfully aware of how much this decision, which seemed sensible then, has cost him. Ajit now battles against a host of new health complications, likely triggered by the steroids that gained popularity as a life-saver during the pandemic.

While treating infectious diseases, doctors usually monitor two important aspects: the viral or bacterial load in the body and the immune system’s response to it. Monitoring the latter is particularly important in case of diseases like COVID-19 for which no effective treatment is available.

The immune system, which is the sole fighter in this case, also does not have any prior experience of eliminating the novel virus. So there is a risk that the immune system could get hyperactive while trying to fight off the contagion and that the resulting inflammatory response — that releases white blood cells or macrophages to engulf and eliminate invaders like bacteria and viruses — assume a severe form.

In case of an acute infection, the inflammatory reaction can even damage the body’s own healthy tissues and organs, a condition known as cytokine storm that has entered common parlance since the onset of the pandemic.

Steroids come to one’s rescue during severe inflammation and cytokine storm. They assuage the hyperactive immune system and thereby keep inflammation under control and block the deadly cytokine storm.

It is imperative that the drugs are prescribed only at the later stages of infection so that they do not weaken the immune response while it is still effectively combating an infection.

The guidelines of the Union Ministry of Health and Family Welfare say a COVID-19 patient should be prescribed steroids only if s / he enters hypoxia — a condition where the oxygen saturation levels report a sudden and drastic fall and which usually sets in during the second week of the infection. An hyperactive immune response can activate factors that induce hypoxia, which in turn, can cause a cytokine storm.

Ajit was, however, prescribed medrol — the commercial name for the steroid methylprednisolone — within the first couple of days of showing symptoms, despite the fact that his oxygen saturation levels were at a healthy 95 per cent and body temperature was between 100 degrees Celsius and 101 degrees Celsius.

These parameters indicate that Ajit was suffering from a mild case of COVID-19, where his immunity is able to fight off the infection. The low-grade fever could and should have been contained with paracetamol alone.

On the third day of treatment, Ajit’s body temperature started to rise and his oxygen saturation levels fell marginally to 94 per cent (against the optimum level of 95 to 99 per cent).

The doctor doubled his steroid dosage — from the initial 16 mg a day to 32 mg. On the sixth day, Ajit developed a high-grade fever, with body temperature reaching 103°C.

Though his oxygen saturation level remained steady, his steroid dosage was doubled again — now to 64 mg a day, administered intravenously to increase the efficacy. The routine continued for another 13 long days till there were visible improvements in his condition.

In the end, Ajit was on high doses of steroid for 20 straight days. The World Health Organization (WHO), in its guidelines on steroid use in COVID-19 patients, mentions that these drugs can be prescribed safely for only seven to 10 days.

Steroids’ dark side

Steroids are essentially synthetic compounds that mimic various natural hormones in humans and act as chemical messengers to regulate basic actions necessary to protect, nourish and maintain the body as well as functions of the reproductive system.

Synthetic steroids developed from sex hormones, primarily the male sex hormone testosterone, are known as anabolic steroids and are mostly used by athletes and bodybuilders to improve muscle mass and physical performance.

The ones used in the treatment of COVID-19 and other infectious diseases belong to the group of corticosteroids. These are synthetic versions of the hormone cortisol produced by the adrenal glands, located on top of both the kidneys.

Cortisol helps regulate our metabolism (how the body uses carbohydrates, fats and proteins and converts those into energy); manages the immune system; regulates blood pressure and blood sugar levels; controls the sleep-and-wake cycle and response to stress; and reduces inflammation.

The functioning of the hormone itself suggests that if used for long or in high potency, corticosteroids can result in a range of side effects, from indigestion and sleep disorders to serious complications like diabetes and damaged liver function.

Since corticosteroids work by suppressing the immune system, they can also make one susceptible to a range of other avoidable infections, especially shingles, chickenpox and measles.

Any abrupt discontinuation of the drug causes sudden steroid deficiency in the body and can result in life-threatening conditions like sudden drop in blood pressure or blood glucose level. Yet, in Ajit’s case, the steroids were stopped abruptly, rather than being tapered off.

A fortnight after recovering, Ajit realised that he had developed abnormal liver function. Blood tests showed his condition had reached the stage of liver cirrhosis.

He now goes to a gastroenterologist for treatment who fears that the complications might have happened because of overdose of steroids.

If Ajit’s treatment regimen sounds familiar, you are likely among the thousands of COVID-19 patients in India who relied on steroids — either with a doctor’s prescription or through self-medication — even though your medical condition did not necessitate it. And by doing so, you have not only risked your chances of recovery but have also jeopardised your health further.

Unofficial estimates show the sale of corticosteroid drugs increased manifold during the second wave of the pandemic.

Little analysis is available to understand the extent to which the medicine was misused during the period and how many people might have suffered from its side effects.

The scale of the problem, however, can be gauged from the sudden surge in the cases of mucormycosis, a rare but aggressive fungal infection that affects the nose, eye and sometimes the brain and results in the death of 50 per cent of the patients.

Current trends show the surge is higher in those with pre-existing diabetes, those on systemic corticosteroids and in people with COVID-19 and those recovering from it.

Several doctors and researchers therefore consider mucormycosis as an indicator of steroid abuse because the condition is triggered by high blood sugar level, a common side effect of steroids.

India has recorded over 50,000 cases of mucormycosis within months after the second wave of the pandemic that peaked in April and May this year, a Union health ministry official confirmed on the condition of anonymity.

“Earlier, mucormycosis was seen in patients with uncontrolled diabetes, but the incidence was low. However, due to COVID-19 treatment, there is a significant increase in the number of cases. Several parts of the country are reporting the increase,” Randeep Guleria, director of the All India Institute of Medical Sciences and a member of the country’s COVID task force, said in a media briefing mid-May.

Guleria is among the several doctors who, towards the later part of the second wave, urged healthcare specialists to stop unmindful prescription of steroids.

He said it was leading to deranged sugar levels in otherwise healthy people and they were returning to hospitals with dangerous fungal infections.

The government too started amplifying the message at almost every press conference and awareness programme.

Following the surge of COVID-19-associated mucormycosis, the Union government on May 20 this year issued a directive asking states to declare the spread of the fungal infection as an epidemic.

Steroid abuse during the second wave ended up unnecessarily adding pressure to the already stressed healthcare system. Lancelot Pinto, pulmonologist at Mumbai’s PD Hinduja Hospital, said: “Not only were we treating COVID-19 patients, we were also burdened with patients, often from tier II cities, who were suffering from ailments triggered by the misuse of steroids.”

This was first published in the 1-15 August, 2021 edition of Down To Earth

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