Dexamethasone

The standard dexamethasone-containing approach benefits about 70% of patients, leaving about 30% with nausea or vomiting. Dexamethasone produced approximately 35% relative risk reduction in mortality among mechanically ventilated COVID-19 patients — an unusually large effect for a viral respiratory failure ICU study. Dexamethasone is purely synthetic with minimal mineralocorticoid activity, unlike other corticosteroids that vary in their tendency to cause sodium and water retention. Substituting methylprednisolone at equivalent doses is reasonable if dexamethasone is unavailable, but outcomes are expected to be similar rather than confirmed. The dexamethasone comparator regimen uses 10 mg orally on day 1 and 5 mg orally once daily on days 2 and 3. The RECOVERY trial was a prospective RCT evaluating dexamethasone 6 mg/day in hospitalized COVID-19 patients; it was stopped early due to a clear mortality benefit. The RECOVERY trial findings were adopted rapidly across institutions even before full peer review, based on a preprint posted to medRxiv. All glucocorticoids share an anti-inflammatory mechanism of benefit, but whether differences in mineralocorticoid activity affect COVID-19…