President Donald Trump was given several treatments soon after he was diagnosed with the coronavirus.
One of those treatments, the steroid dexamethasone, is usually reserved for seriously ill patients.
Experts told Business Insider that giving Trump that steroid suggests either that he's being overtreated for a mild case of COVID-19 or that he could be more ill than his team is letting on.
Outside the walls of Walter Reed National Military Medical Center, doctors are puzzling over President Donald Trump's coronavirus treatment regimen.
Since being diagnosed on Thursday, the president has received a pair of experimental treatments, as well as the steroid dexamethasone. Physicians not involved in Trump's treatment said the experimental therapies may be helpful but raised questions about why he got a steroid usually reserved for serious cases.
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"If the president is more ill than the press conferences are letting on, then his treatment may well be reasonable," Dr. Patrick Jackson, an infectious-disease specialist at the University of Virginia, told Business Insider. "If the president is doing as well as the press conferences describe, then his treatment is very aggressive."
In Business Insider's conversations with 20 doctors over the past four days, a common assessment emerged: Either Trump is being overtreated for a mild case, which comes with its own risks, or he's more ill than his team has let on.
The experts acknowledged that it's difficult to offer opinions about the president's care, since they're not directly involved in the treatment decisions. They also said the White House's incomplete and at times contradictory disclosures about the president's condition further undermined independent doctors' ability to assess the situation.
"Right now, it's kind of like we're driving in the dark," Dr. Taison Bell, an infectious-disease physician at the University of Virginia's medical center, told Business Insider on Saturday.
Decisions about Trump's treatment regimen raise questions
Trump's physician, Dr. Sean Conley, said on Saturday that the president's medical team was trying everything it could.
"We're maximizing all aspects of his care, attacking this virus, you know, multipronged approach," Conley said in a briefing at Walter Reed, where the president has been hospitalized since Friday. "I didn't want to hold anything back. If there was any possibility that it would add value to his care and expedite his return, I wanted to take it, and the team agreed, and that's how we proceeded."
Trump is 74, and his age, weight, and sex put him at increased risk of a serious case of COVID-19. Still, his doctors have said the president is getting better. Trump is set to return to the White House on Monday evening, where he'll receive round-the-clock care at the White House medical unit. His dexamethasone treatment will continue there, Conley said.
But starting Trump on dexamethasone raises questions about the severity of his condition, said Dr. Thomas McGinn, the physician-in-chief at Northwell Health. The National Institutes of Health recommended against giving dexamethasone to patients who don't need assistance breathing, stipulating that the steroid is recommended only for patients who need a ventilator or extra oxygen.
"Either he's sicker than they are letting on, which would indicate why they gave the dexamethasone, but I don't think that's the case if they are considering discharging him. That makes no sense to me," McGinn said.
The other possibility, he said, is that "they are being overly aggressive because he's the president of the United States."
Trump got dexamethasone after his condition appeared to worsen
Trump started taking dexamethasone on Saturday, after he showed symptoms indicating that a COVID-19 case may be becoming more serious — the level of oxygen in the president's blood dipped, and he was given supplemental oxygen.
Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said that treatment decision made sense. A study on the use of dexamethasone to treat COVID-19 found that it reduced deaths among patients who needed ventilators or supplemental oxygen.
"Dexamethasone is what we use on anybody requiring supplemental oxygen," Adalja told Business Insider. "It's standard even if it's a transient need for oxygen."
But there's little research on how the steroid works in combination with the two experimental treatments that Trump received.
'He's in a higher-risk category'
The two experimental treatments Trump received are remdesivir and an antibody cocktail. Administering them early can help the body fight the coronavirus, said Dr. Mangala Narasimhan, who oversees ICU care at Northwell Health.
"The thought is if you can reduce the viral burden with an antiviral early on, then maybe the progression will be halted in some way," she said, adding: "Given the fact he's 74, a male, and obese, I think he's in a higher-risk category, so his chances of getting sick from this are higher. They are trying to prevent that from happening."
Remdesivir is a virus-fighting drug that was developed to treat Ebola. Studies have found that it can help hospitalized patients with COVID-19 recover faster. The Food and Drug Administration has given emergency authorization for the drug's use in hospitalized patients, and the NIH guidelines recommend remdesivir for hospitalized patients who require supplemental oxygen.
The antibody treatment, meanwhile, is made by the biotech company Regeneron and is not authorized by the FDA to treat COVID-19. It aims to boost the body's immune response to help fight the virus.
Trump's VIP status may affect the care he gets
Trump's status as a VIP patient might influence the care he's getting, leading doctors to make treatment decisions they otherwise wouldn't.
"The medical team is going to be under significantly more pressure," Dr. Uché Blackstock, an emergency-medicine physician and the founder of Advancing Health Equity, told Business Insider, "because he is the president, and that may influence the decisions that they make, or have to make, about his course of treatment."
But throwing all possible options at an infection is not always in the patient's best interest.
"There's this illusion that doing more is somehow better. Of course, that's not true when the things you're doing haven't been proven to work," said Dr. Jeremy Faust, an emergency-medicine doctor at Brigham and Women's Hospital. "So what you're really doing in those situations is you're potentially putting your patients at risk without really giving them much of a benefit."
Trump could be pushing for aggressive treatment regardless of what the science and his own doctors say.
"Donald Trump is the VIP of VIPs — and just by his personality, he's aggressive, he wants to do stuff," Faust said. "I don't envy the physicians who have to have these conversations."
But Conley resisted the notion that Trump was directing his own care on Monday, calling the president a "phenomenal patient."
"He's holding court with those of us around him, the whole team, going over all the specifics, the testing, what the future is, and we have a back and forth on what's safe and what's reasonable," Conley said. "He has never once pushed us to do anything that is beyond what's safe and reasonable practice."
'It's a very tricky illness to deal with'
Trump's dexamethasone treatment may be evidence that he's getting overly aggressive VIP care, Jackson said.
But using a steroid alongside the antibody cocktail may be counterproductive, since the latter mimics the body's natural immune response to fight off the virus while steroids tamp down the immune system.
"If he gets steroids, whatever that antibody was is gone now," said Dr. Panagis Galiatsatos, a pulmonary physician at Johns Hopkins Bayview Medical Center. "You're trying to just stop that chaos of an immune response."
Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center, cautioned that no matter the president's apparent condition now, he's not out of the woods yet.
"It's a very tricky illness to deal with," Schaffner said. "I call it a stealth infection, because even without the dexamethasone, you can look pretty good and then crash a couple of days later and get very seriously ill and have to be put into the intensive-care unit."
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