The recent news that dexamethasone reduces deaths covid-19 is a good news story for chronic pain physicians on a number of different levels. As we are starting to emerge from the covid-19 epidemic and think about trying to see chronic pain patients, we are faced with the dilemma of what treatments we can offer our patients.
http://www.ox.ac.uk/news/2020-06-16-dexamethasone-reduces-death-hospitalised-patients-severe-respiratory-complications
Should we be using cortisone?
Cortisone injections, in one form or another, play a significant role in chronic pain management. The current epidemic has led to a lot of internal debate within our department about whether we should offer these. This is on the basis that the cortisone can impair the inflammatory response. While this is the basis of the therapeutic effect in terms of pain relief, this dampening of the inflammatory response could also, in theory, make one more susceptible to bacterial or viral infection. This has led to a degree of confusion about whether cortisone injections should be offered and if so, on what terms.
Guidance
Guidance has come from the Faculty of Pain Medicine (see here) as well as the British Association of Spinal Surgeons (see here). Essentially, both of these bodies suggest that there is no firm evidence for or against cortisone injections – of course there isn’t – how could there be. Essentially, as in all aspects of medicine, it is a case of balancing the risk of injection against any potential benefit. Like all informed consent, this is taken in partnership between physician and patient.
Dexamethasone Reduces Deaths in Covid-19
This latest work from Oxford suggests that dexamethasone has a directly beneficial effect in those suffering from covid-19. This study showed that dexamethasone reduced death rates by about one third in the sickest group (on ventilators) and by about 20% in the intermediate group (on oxygen therapy). Such was the strength of evidence, the study was halted early as the researchers felt that they had gathered enough data to be able to establish that the drug has a meaningful effect.
What Now?
Does this study give more confidence for those wishing to offer cortisone injections in the current covid-19 era? The basic principals of informed consent still apply and, indeed, the guidelines issued by both the faculty of pain medicine (FPM) and the British Association of Spinal Surgeons (BASS) are still valid. The evidence presented in this paper strongly suggests that dexamethasone is beneficial in the treatment of covid-19, presumably on on the grounds of its potent inflammatory effect suppressing a systemic inflammatory response. However, the question remains, would its immuno-suppressing qualities make one more susceptible to acquiring the infection after exposure?