The Art of the Steroid

There has been a lot said about corticosteroids in the past few days. (FYI, these are quite different from anabolic steroids which turned Arnold Schwarzenegger into… Arnold Schwarzenegger.)

For those who are unfamiliar with them, corticosteroids are synthetic drugs that mimic the effects of hormones that our body produces to suppress inflammation as well as the immune system. They can be used to treat eczema, asthma, lupus, and other conditions in which our immune system mistakenly attacks our body’s own tissues.

So why would they be used in an infectious disease like COVID-19? After all, it’s really important to have our immune system going full throttle when we are fighting off an infection. So giving these kinds of steroids early in an infectious disease can be a dicey proposition, blunting or maybe even shutting down a life-saving immune response.

Where steroids may be helpful is later, when the body is mounting all kinds of responses to the invaders, including an inflammatory response. Inflammation can result in fevers and a buildup of fluids and white blood cells in areas where they can cause more harm than good. This especially seems to be a problem for older people after the first few days of COVID-19, and steroids can reduce inflammation and fluid collection in the lungs to allow for more normal breathing.

Which raises the question: Why did Donald Trump get steroids when he got them? It seems like they were given very early in his course at a time when his doctors might have been concerned about hobbling his own immune response. On the other hand, if he was much sicker than is being let on, perhaps they had to weigh the risks and benefits and felt that, despite the dangers, it was necessary to allow him to breathe. The final — and perhaps most troubling — possibility is that the president has been directing his own care, and having heard that steroids are good, demanded that he get that treatment immediately.

To complicate matters further, anyone who has been on systemic corticosteroids knows that they can make you feel weird and powerful and loopy. The article “Evidence of prednisolone induced mood change (‘steroid euphoria’) in patients with chronic obstructive airways disease” states, “It is a clinical impression that some patients given oral corticosteroids develop a sense of wellbeing that is ‘inappropriate’ to improvements in physical health. This has been termed steroid ‘euphoria’…” With Trump tweeting “Feeling really good! Don’t be afraid of Covid. Don’t let it dominate your life… I feel better than I did 20 years ago!” one has to wonder. And while it is tempting to say, “Well, with Trump, how could you even tell?” at a certain point there is usually a crash, both in mood, and in the case of COVID-19, symptoms.

Because, if the president truly did start having symptoms last Friday, we are now on day 4. For a man of his age and heft (and with the possibility of other risk factors he has kept from the American public), we are about three or four days away from the worst of it. And when that comes, it won’t be pretty.

Trump is dancing as fast as he can — and God knows the corticosteroids are helping him — but like so many high-stakes deals he has made in his life, he has kept his eye only on short-term profits. I am truly afraid that, this time, physical bankruptcy is only days away, and the most generous tax code in the world is not going to bail him out of this one.

Pediatrician, Educator, Singer, Writer, Advocate, Actor, Improviser. Views are my own, not those of any institution where I’m employed.

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