Talk:Dexamethasone

Untitled

Hi. I have some medical allergies to what I know as Keflex and Pertussin. I recentely underwent a surgery to get my wisdom teeth out where my doctor used the drug dexamethasone. I had a reaction and was rushed to ER with trouble breathing (my body was working on only 40% the regular oxygen level) and the doctors kept me there until I could breath but wouldn't tell me why I was there or what caused it. My question is, are there any significant links from this steroid to the medicines that I listed? Do they have any of the same chemical makeup? And why would my doctor not know to cross-reference these if there is? Also wondering if my doctor would be liable for the ER bills because of overlooking the listed allergies...?

COVID-19

https://www.bbc.com/news/health-53061281 - trial indicates it is effective in treating serious cases. I think this should be added. BBC is an accepted 2ndary source. https://boingboing.net/2020/06/16/doctors-say-do-not-take-dexame.html says do not take it as a prevention of covid-19 Kdammers (talk) 05:27, 17 June 2020 (UTC)

There are editing restrictions in place for this article. Preprints and other non-peer-reviewed sources should not be used. An active consensus is required to add the content. Whywhenwhohow (talk) 14:53, 17 June 2020 (UTC)

And yet, no consensus is needed to remove the entire section? You said these sources can't be used, then straight up deleted the whole section one minute later. That's not consensus, that's not even enough time to have a simple conversation about it. GyozaDumpling (talk) 15:26, 17 June 2020 (UTC)

Sure. So let's try to reach some sort of consensus. Do editors here believe that this article should contain some reference to COVID-19, provided that it makes clear that the preliminary results of the RECOVERY Trial have not yet been formally published? Hallucegenia (talk) 15:43, 17 June 2020 (UTC)

When BBC News (or any other news source) simply reports a press release, it does not meet the MEDRS standard we expect for secondary sources. The only thing it adds is that the BBC finds it sufficiently newsworthy to report it. The sort of secondary sources needed to support biomedical claims are systematic reviews, meta analyses and statements from inter/national health bodies. These add the analysis of primary sources necessary for us to be able to write content with confidence. Until the paper is published and analysed, we should be confining our content to nothing more than noting the preliminary results, without making any claims of fact about the efficacy of the treatment. --RexxS (talk) 16:20, 17 June 2020 (UTC)

"we should be confining our content to nothing more than noting the preliminary results, without making any claims of fact about the efficacy of the treatment". Totally agree. Hallucegenia (talk) 17:05, 17 June 2020 (UTC)

Since we have some less experienced editors – and since it is unreasonable to expect anyone to read all the policies and guidelines – I want to note that Wikipedia needs consensus to include information in articles, not to remove information that you believe is bad. That is the point behind the WP:ONUS section of policy. The editor who wants to include something has to produce some sort of consensus for including it. The editor who wants to remove it is free to do so, unless there is evidence of a consensus to include it. WhatamIdoing (talk) 00:26, 18 June 2020 (UTC)

Comments re inclusion of COVID-19

• Yes - include This is an important result announced by a highly respected and authoritative reliable source. Hallucegenia (talk) 15:43, 17 June 2020 (UTC)
• Yes - include I agree with Hallucegenia. The original section disclosed the lack of reliable study results. I believe that statement was sufficient, and didn't warrant deletion. GyozaDumpling (talk) 16:00, 17 June 2020 (UTC)
• Yes - include. Not only is the BBC a reliable source, the Chief Medical Officer for England is at least one original source. Alistair1978 (talk) 16:05, 17 June 2020 (UTC)

Yes - include with the caveats that it is a preliminary result. Anywikiuser (talk) 16:10, 17 June 2020 (UTC)

• Yes - include - caveated to show lack of peer-reviewed results.The clinical instruction of the CMO to treat patients is notable of itself IMO, providing we don't pass comment on its efficacy or lack thereof. Best, Darren-M talk 17:57, 17 June 2020 (UTC)
• Yes - include - I think we have a clear consensus here -- {{u|Gtoffoletto}}  ^talk 22:18, 17 June 2020 (UTC)

I've reintroduced the COVID-19 section. I've kept the stronger sources I saw here and in the previous edits. I've tried to make it clear those are preliminary results. Comments welcome. I think something should be said in the lead as well probably. -- {{u|Gtoffoletto}}  ^talk 22:52, 17 June 2020 (UTC)

Thank you for doing that. Hallucegenia (talk) 08:53, 18 June 2020 (UTC)

Nomination of reliable sources

And, IF we do agree to include a reference to COVID-19 in the article, can we also agree in advance on what reliable sources we use to support the following statements? Feel free to add (or strikethrough) statements and sources in the list below: Hallucegenia (talk) 17:29, 17 June 2020 (UTC)

"On 16 June 2020, the UK RECOVERY Trial announced a preliminary result that low-dose dexamethasone treatment can reduce the death rate by approximately one-third in COVID-19 patients on ventilators and by one-fifth in COVID-19 patients on oxygen. Benefits were only observed in patients requiring respiratory support. As of 17 June, the full details of this research have not yet been published."

• RECOVERY Trial Press release 16 June 2020
• BBC Article: Coronavirus: Dexamethasone proves first life-saving drug

"Dexamethasone has also been used to treat covid 19 patients who are in critical condition."

• BBC Article "Coronavirus: Dexamethasone being used to treat NHS patients today"

"the Chief Medical Officers of the United Kingdom have all recommended that 'Clinicians should consider dexamethasone for the management of hospitalised patients with COVID-19 who require oxygen or ventilation.' "

• COVID-19 Therapeutic Alert

  Support using this source. It is a genuine MEDRS-compliant secondary source coming from national health bodies who report on and offer some analysis of the preliminary results. I can't see any point or justification for using any of the other sources (the initial press release and two news reports). We can use it to summarise the conclusions of the study and to note the recommendations to implement immediately. --RexxS (talk) 21:31, 17 June 2020 (UTC)

  Support this is a very strong secondary source. -- {{u|Gtoffoletto}}  ^talk 22:18, 17 June 2020 (UTC)

  How about Reuters, which has picked up the story and presented comments by a number of doctors? Kdammers (talk) 02:54, 18 June 2020 (UTC)

Not for medical claims as far as I know. WP:MEDRS is where you'll find those answers. -- {{u|Gtoffoletto}}  ^talk 08:26, 18 June 2020 (UTC)

Publication of results

I notice that the RECOVERY Trial results have been published on the MedRXiv preprint server here: [1]. Hallucegenia (talk) 11:07, 23 June 2020 (UTC)

I have two questions on this paper:

• Does preprint publication like this count as a reliable source according to WP:MEDRS? Can we change the text to be more definitive now?
• Should we report the result that Dexamethasone increased mortality in patients who were not receiving respiratory support? The authors only say that "the results are consistent with possible harm in this group".

Hallucegenia (talk) 11:27, 23 June 2020 (UTC)

@Hallucegenia: for obvious reasons, preprints are not considered a reliable source for anything other than their own existence. The whole point of preprints is to give other experts and researchers a chance to examine, analyse and critique the paper. As that process unfolds, those experts and researchers will publish their conclusions which allow us to report further. We base our text on those secondary sources, not on preprints and primary sources, and I don't see that the statements in the secondary sources have changed at this moment.

There is no result that "Dexamethasone increased mortality in patients who were not receiving respiratory support" for us to report. The figures given, "17.0% vs. 13.2%, RR 1.22 [95% CI 0.93 to 1.61]; p=0.14", mean there is no statistical difference between the trial and the control groups and the researchers would need a more highly powered trial to assert anything other than that. I seriously doubt that such a trial would now ever take place.

When a reliable secondary source makes a statement regarding the effect of Dexamethasone on those who were not receiving respiratory support, we'll be able to use it.

So far as I can see, we only have the letter from the UK CMOs (Dexamethasone has been demonstrated to have a clear place in the management of hospitalised patients with COVID-19. There were no excess harms identified in using this dose of dexamethasone in this patient population. ... Clinicians should therefore consider dexamethasone for the management of hospitalised patients with COVID-19 who require oxygen or ventilation.) and the WHO press release (It is important to reserve use of the steroid dexamethasone for the treatment only of serious cases of COVID-19, for which it has been shown to have a benefit, the head of the World Health Organizations’s emergencies program said on Wednesday. "It’s exceptionally important in these cases that the drug is reserved for severely ill and critical patients who can benefit from this clearly," Mike Ryan told a briefing.).

When other reliable secondary sources appear, we may be able to say more, but for now, I don't think we're in a position to report beyond what those two sources say. As the UK CMOs state that there are no excess harms in those hospitalised with COVID-19, it would be inaccurate for us to say the opposite. --RexxS (talk) 12:06, 23 June 2020 (UTC)

Understand. But should we at least say "There was no benefit (and the possibility of harm) among patients who did not require oxygen.", which is a direct quote from the published preprint? And we must change the sentence "experts have called for the full dataset to be published", as that has now been ovetaken by events. Hallucegenia (talk) 12:30, 23 June 2020 (UTC)

I'm not sure I'm getting my point across to you. We don't have a source for a direct quote from the preprint because the preprint isn't a valid source for us to make biomedical claims. I have seen no secondary source that states there is a possibility of harm. Of course, there is always some possibility of harm with any drug, but I assure you that the results of the trial present no evidence of that.

I do agree that the events have overtaken the second sentence you refer to. I suggest we simply remove it as irrelevant now. The alternative (something like "on the release of the preliminary results, experts called for the full dataset to be published,{ref} and the full paper was released as a preprint six days later.{ref}") would be difficult to cite right now until we get a news report or something similar commenting on it, otherwise it has a tinge of original research. Remember that we report what has been published about research, not publish our own research. --RexxS (talk) 15:26, 23 June 2020 (UTC)

The letter from the UK CMOs is based on the pre-publication press release information from the RECOVERY trial. It appears that all that exists is the RECOVERY press release and its preliminary report preprint along with rehashes and opinions of them. Whywhenwhohow (talk) 20:16, 24 June 2020 (UTC)

Yes, and it's the opinions expressed in "guidelines or position statements from national or international expert bodies" that we're interested in. You can find all that at WP:MEDRS --RexxS (talk) 21:08, 24 June 2020 (UTC)

Agree, that is all that exists at this stage. But the letter from the CMOs constitute very clear clinical practice guidelines, which have been immediately adopted throughout the UK National Health Service. And WP:MEDS, in the section Assess evidence quality WP:MEDASSESS, asserts that "Clinical Practice Guidelines" are at the very top of the pyramid when it comes to ranking evidence in medicine. Hallucegenia (talk) 21:18, 24 June 2020 (UTC)

Those guidelines seem to suffer the possible problems outlined in medical guideline:

Guidelines may have both methodological problems and conflict of interest. As such, the quality of guidelines may vary substantially, especially for guidelines that are published on-line and have not had to follow methodological reporting standards often required by reputable clearinghouses. Guidelines may make recommendations that are stronger than the supporting evidence.

Whywhenwhohow (talk) 01:37, 25 June 2020 (UTC)

That's a Wikipedia article. Are you seriously asking other editors to take advice from that? If you can read the article, why can't you read WP:MEDRS, which lays out the actual standards for sourcing in our articles? Do you seriously contend that the letter from the UK Chief Medical Officers, advising an update to clinical practice recommendations, is not one of the top quality secondary sources that MEDRS requires? --RexxS (talk) 15:46, 25 June 2020 (UTC)

RexxS In your reply above you referred to that article where you wrote -- it's the opinions expressed in "guidelines or position statements from national or international expert bodies" that we're interested in. I've read WP:MEDRS and it refers to the same Wikipedia article. The guidelines from the CMO referred to the RECOVERY trial so it appears that those guidelines are stronger than the supporting evidence. The CMO may have biases about or ties to the RECOVERY trial. Of course we can use it since it is a guideline but what is the rush to add content to the article that isn't validated and verified appropriately? Whywhenwhohow (talk) 18:44, 25 June 2020 (UTC)

@Whywhenwhohow: I'm glad you're working from MEDRS. I hope you've realised that the link from MEDRS is there to give the reader the background on what a medical guideline is, not to be a supplement to our guidance. It is indeed true that the statement from the UK CMOs is stronger than its cited source. We value the guidance and position statements from expert bodies well above primary sources, such as a RCT, because we have implicit confidence in the knowledge and expertise of the members of the body making those pronouncements. That layer of authority is what elevates the primary source to a good quality secondary one. You can't validate or verify sources that are considered top-quality – what sources do you think you would use to do that? If you contend that the the source is inappropriately validated and verified, please try to explain how.

There are now more secondary sources becoming available on the topic: you may care to compare this editorial from the BMJ with its principal source, a press briefing by the DG of the WHO. See if you can figure out which is the stronger source, and which is usable for Wikipedia content. --RexxS (talk) 19:34, 25 June 2020 (UTC)

Another guideline to consider:
The National Institutes of Health COVID-19 Treatment Guidelines Panel Provides Recommendations for Dexamethasone in Patients with COVID-19
COVID-19 Treatment Guidelines Panel (25 June 2020). "Dexamethasone". National Institutes of Health. Retrieved 25 June 2020.
Whywhenwhohow (talk) 16:20, 26 June 2020 (UTC)

That's a top-quality source and agrees with the conclusions of the UK CMOs and the WHO, so it helps increase our confidence in those. I'm impressed by how clearly it covers the issues in "Additional Considerations", particularly the recommendation that highlights the importance of clinicians reviewing "the patient’s medical history and assess the potential risks and benefits of administering corticosteroids to the patient". --RexxS (talk) 17:44, 26 June 2020 (UTC)

FYI, Health Canada suggests it should be considered but they have not updated their management of patients with moderate to severe COVID-19 - Interim guidance

Among hospitalized patients who have COVID-19 and require supplemental oxygen or mechanical ventilation, clinicians should strongly consider:

• dexamethasone 6 mg IV for 10 days (or until discharge if earlier) or equivalent glucocorticoid dose

This guidance is not meant to replace clinical judgment or specialist consultation.

— "Coronavirus disease (COVID-19): For health professionals". Public Health Agency of Canada. 2020-06-29.

Whywhenwhohow (talk) 23:05, 11 July 2020 (UTC)

Concerns about treatment with dexamethasone

I've removed a preprint and the content reporting it, and added a quote from the Director-General of the WHO that illustrates the concerns much better and more authoritatively, IMHO. --RexxS (talk) 00:32, 26 June 2020 (UTC)

Research

At some point we ought to consider moving the COVID-19 section out of Research and into Medical uses. What would be a sufficient trigger for that discussion? --RexxS (talk) 00:45, 26 June 2020 (UTC)

Updated indications by the FDA, EMA, et al. Whywhenwhohow (talk) 03:51, 26 June 2020 (UTC)

@Whywhenwhohow: I moved it out but you reverted. As per sources in the article we have NIH with a strong recommendation for the drug and WHO indicating it is updating guidelines to include it. I'd say the conditions have been met. You disagree? It is in widespread use at this point (so much so it is in shortage) -- {{u|Gtoffoletto}}  ^talk 11:35, 13 July 2020 (UTC)

The guidelines are based on preliminary results from one study and a shortage doesn't indicate widespread use. There may be hoarding due to all of the press about it. The NIH guideline is not strong. It says "based on these preliminary results the panel recommends", then goes on to qualify the recommendations along with various considerations, and then states that they may be revised after reviewing the published results of the study and the results of other ongoing studies. The WHO hasn't updated its treatment guidelines yet. We should be careful not to rush. Hydroxychloroquine was previously considered a "cure". Whywhenwhohow (talk) 02:49, 14 July 2020 (UTC)

@Whywhenwhohow: You can read the recommendation by the NIH here: [2] It is classified as AI which is the highest possible recommendation (A = Strong; I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints). It's as high a recommendation as it gets. The WHO stated they are updating their guidelines to include it. And other national agencies have done the same such as the UK (obviously). -- {{u|Gtoffoletto}}  ^talk 05:53, 14 July 2020 (UTC)

@RexxS: any thoughts on this? -- {{u|Gtoffoletto}}  ^talk 09:10, 16 July 2020 (UTC)

I think we need to summarize the source carefully, with its caveats, and not lean too heavily on an editorial interpretation of what "A1" means in this instance. Alexbrn (talk) 11:32, 16 July 2020 (UTC)

It's not an editorial interpretation. It's what the NIH say in their own statement: Hallucegenia (talk) 15:20, 16 July 2020 (UTC)

"Recommendation Rating Scheme:

"Rating of Recommendations: A = Strong; B = Moderate; C = Optional

"Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion"

It's part of what they say. Saying that NIH are giving dexamethasone their strongest possible backing, without qualification, would be a distortion. Alexbrn (talk) 15:35, 16 July 2020 (UTC)

I think we reach the point of moving out of Research and into Uses when an international or national body creates an advisory note to recommend the drug for clinicians to consider as a treatment. I also think it's important we report the caveats and that we make as dispassionate and accurate a summary of what is recommended as possible. We should not be editorialising: it is preferable to state "The NIH recommended ...", rather than to state "The NIH strongly recommended ...", unless they used the word 'strongly' themselves. It's not our job to analyse a paper and add our judgement on the conclusions or recommendations if that judgement does not exist explicitly in the source, or in another secondary source commenting on the first. All just imho, of course. --RexxS (talk) 16:19, 16 July 2020 (UTC)

Agreed. As endorsed by several national health authorities, dexamethasone is rapidly becoming standard of care of severely ill COVID-19 patients. Furthermore there is a recent review (PMID 32663575) that support its use to combat cytokine storm induced by COVID-19. Of course, it should also be made clear that dexamethasone should only be used for the most severely ill patients as depressing the immune system is very likely to be counter productive is less severe cases. Boghog (talk) 18:59, 16 July 2020 (UTC)

I think that when we add it to the Uses section it should be new text instead of just moving all the text from Research. It makes sense to keep text in Research since it is still being tested and evaluated. Whywhenwhohow (talk) 23:49, 17 July 2020 (UTC)

the Recovery Trial result has now been published in the NEJM: [3] Hallucegenia (talk) 17:10, 18 July 2020 (UTC)

That's good, but we have to remember that it remains a primary source, and still needs a secondary source to do the analysis for any conclusions about biomedical effects to be used in Wikipedia. --RexxS (talk) 18:23, 18 July 2020 (UTC)

@RexxS:I think we reach the point of moving out of Research and into Uses when an international or national body creates an advisory note to recommend the drug for clinicians to consider as a treatment. I agree. This condition has already been met. The NIH (see sources) has given a reccomendation for use with exact dosages etc. The UK also has a clinical recommendation through the NHS [4]. This is now in widespread use in several major countries. I'm editing the article accordingly. -- {{u|Gtoffoletto}}  ^talk 08:20, 22 July 2020 (UTC)

@Gtoffoletto: The non-usage trial details should be in a separate section. I moved them to the history section. Whywhenwhohow (talk) 21:23, 22 July 2020 (UTC)

@Whywhenwhohow: I was thinking the same. I think it's good! -- {{u|Gtoffoletto}}  ^talk 10:02, 23 July 2020 (UTC)

Use with Spironolactone

"Scientists offer hope after trials show a combination of spironolactone and dexamethasone work far better than dexamethasone alone" https://www.telegraph.co.uk/news/2021/11/27/spidex-drug-cocktail-could-defeat-new-covid-variant/ 2600:8804:6600:83:89EB:A1DD:FFCA:B3CA (talk) 17:34, 29 November 2021 (UTC)

Trump treatment

On 4 October 2020, doctors treating Donald Trump for COVID-19 announced that Trump had been given dexamethasone.

I added this edit to the end of the History section, but it was reverted three minutes later with the reason for revert listed as "Undue factoid". The case for including this is that the use of this drug to treat a highly notable person is definitely relevant. I'd like to see consensus on this, and I'd like to see any arguments against inclusion linked to WP:POL. 73.158.166.97 (talk) 18:23, 4 October 2020 (UTC)

References

See WP:NOT. Wikipedia is supposed to be a "summary of accepted knowledge" on its topics. Some "breaking news" style trivia about Trump adds precisely nothing to our understanding of Dexamethasone. If some analytical commentary on this appears in RS, then we can think again. Alexbrn (talk) 20:00, 4 October 2020 (UTC)

Does not mention a specific thing under WP:NOT that this is, and that Wikipedia is not. A drug is evaluated by its usage. The treatment of a major world leader using this drug definitely tells us something valuable about usage. "Trivia" and "analytical commentary" are not linked to WP:POL. WP:NEWSORG is listed under WP:RS. Los Angeles Times is definitely an established national news organization, and carries weight as a reliable source. I restored the fact to the article, this time adding AlJazeera and the New York Times for additional credibility. 73.158.166.97 (talk) 20:57, 4 October 2020 (UTC)

I removed it WP:NOTNEWS. You asked for consensus. Please wait until consensus is reached before adding it again. --Whywhenwhohow (talk) 21:36, 4 October 2020 (UTC)

This is not news under WP:NOTNEWS. It does not meet any of the four categories of WP:NOTNEWS. It is not original reporting, because it cites three reliable sources that contain the fact. It is not a news report, because it is not written in news style and it only contains the most important piece of information in one sentence. Additionally, this does not receive any undue coverage because it is recent. The fact that this drug is used to treat a sitting US president for a life-threatening infection will be as Wikipedia-worthy 40 years from now as it is today. It is not a who's who, because it only mentions the one relevant person by name. It is not a diary, because this is not the Donald Trump article. Additionally, the White House COVID-19 outbreak article currently has more detailed writing about Trump's Dexamethasone treatment, and with fewer reliable sources. It definitely deserves at least a short mention on this article. 73.158.166.97 (talk) 23:07, 4 October 2020 (UTC)

Include. It is a useful piece of information. I specifically came to this page because I wanted to learn more about the drug after I learned that Trump was treated with it and was disappointed to find no mention of it in the main article and wondered when I found no mention of it if I had been mistaken about Trump taking this drug. 2600:1700:DC50:5560:4D4E:8A:E80E:7E77 (talk) 18:56, 8 October 2020 (UTC)

I would not include this piece of information. It doesn't add any information regarding Dexamethasone and it will be irrelevant in a couple of months. WP:NOTNEWS -- {{u|Gtoffoletto}}  ^talk 10:20, 10 October 2020 (UTC)

Dimensional ambiguity

1st major paragraph, last sentence. "Dexamethasone has anti-inflammatory and immunosuppressant effects.[9]" This statement is counterintuitive biologically, consider discerning affect and effect both practically and parasympathetically (primary through tertiary active action of medication instead of biological counter-reaction, or the even less desirable redundant primate model.) Mrianwilliam (talk) 10:37, 3 May 2022 (UTC)