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Vincent Rajkumar Profile picture
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28 May, 8 tweets, 3 min read
Important to realize that we use steroids like dexamethasone as anticancer drugs (for myeloma) to kill the same cells that make antibodies & help us fight infection.

They are not antivirals. They are anti immune system. They help the COVID virus if given early or inappropriately
When treating the cancer multiple myeloma, we have found that giving high doses of dexamethasone cause more deaths than low doses. More steroids is NOT better. Less is more. @TheLancetOncol thelancet.com/journals/lanon…
Dexamethasone and other steroids will make any kind of fever disappear and make people feel better, but behind the scenes they cause harm when used incorrectly.

We found all kinds of side effects are higher with higher dose of dexamethasone. From blood clots to infections.
Dexamethasone is needed in COVID only if the oxygen levels go low. The right dose for COVID is 6 mg for 5-10 days. Once done, there is no need to taper. Just stop.

The equivalent dose of methylprednisone /solumedrol is 32 mg once a day.

Used correctly steroids save lives.
We use steroids in COVID when there is low oxygen because by that stage the virus is already being controlled by the immune system but the associated inflammation is damaging the lungs. When used carefully, steroids put a slight brake on the immune system & reduce lung damage.
Side effects to note: Steroids will increase the blood sugars. They can unmask undiagnosed diabetes. Together with the effect of suppressing immune system, they predispose to mucor and all kinds of bad infections.
Steroids also cause severe mood disturbances, including anxiety, irritability, aggression. They can also increase the blood pressure. These side effects should be monitored along with blood sugars every day when on treatment.
Related infographic developed by @IndiaCOVIDSOS

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Vincent Rajkumar Profile picture
27 May
Evidence that current vaccines protect against B1.617 variants seen in India. #VaccinesWork

1/ Although 7 fold more resistant to neutralizing antibodies from convalescent or Pfizer/Moderna vaccinated people, ALL vaccinated sera still able to neutralize. biorxiv.org/content/10.110…
2/ UK study: 88% efficacy with Pfizer, & 60% with AZ against symptomatic COVID. This is only slightly lower than original RCTs of these vaccines, & when compared to B.1.1.7. in this study.

Likely much more efficacy against severe COVID.

Link to preprint: khub.net/documents/1359…
3/ Full vaccinated healthcare workers in India seem to be protected from severe COVID and deaths to a high degree. There are definitely some reports of loss of life in fully vaccinated, but I think these are rare. See thread.
Read 7 tweets
Vincent Rajkumar Profile picture
26 May
How and why I treat high risk smoldering multiple myeloma (SMM). Thread.

1/ Based on the progression risk curve over time, and genomic analysis, SMM is now considered a heterogenous clinical entity in which 50% of patients have premalignancy and 50% asymptomatic malignancy.
2/ These two groups can be considered as high risk SMM (asymptomatic malignancy) and intermediate/low risk SMM (premalignancy).

We are specifically concerned about high risk SMM, defined as 50% risk of progression to myeloma over 2 years.
3/ Patients with high risk SMM can be identified by the Mayo 2018 criteria: Also called the 20-2-20 criteria.

BMPC >20%
M spike >2
FLC Ratio >20

Any 2 of the 3 risk factors is considered high risk SMM. @MayoMyeloma @MayoCancerCare @myelomaMD
Read 13 tweets
Vincent Rajkumar Profile picture
25 May
Over 500 doctors have reportedly died of COVID in India in the second wave. Can someone confirm report here that >95% were not yet vaccinated? @DailyhuntApp @IMAIndiaOrg @Milan_reports @soutikBBC @PSampathkumarMD

H/T @amitsurg
m.dailyhunt.in/news/india/eng…
In my discussions with leaders of 3 large hospitals, fully vaccinated healthcare workers got COVID but didn't get serious illness. @spkalantri

There are some deaths despite full vaccination. But my sense so far is fully vaccinated are highly protected from severe disease.
Besides vaccination status, the other consideration is viral dose. Healthcare workers are at risk of high viral dose exposures and multiple repeated exposures which puts them at higher risk. The loss of life described below is tragic. Some are very young doctors.
Read 5 tweets
Vincent Rajkumar Profile picture
24 May
Worth remembering that people who have raised alarm and advocated caution have been more right on COVID.
It has been a hard year trying to project appropriate level of caution and worry, when faced with some who didn't like masks, some who felt it's just the flu, and some who felt we can just let people get herd immunity by natural infection. @dwallacewells nymag.com/intelligencer/…
I keep thinking of the times I have been wrong. Where I tried to project optimism: cross reactive immunity protecting India, variants unlikely to be more transmissible & lethal, dismissal of importance of neutralizing antibody levels, potential severity of reinfections.
Read 5 tweets
Vincent Rajkumar Profile picture
23 May
Mucormycosis with COVID in India:
#BlackFungus

Many theories on why incidence is high.

Fix what's in your control:
1) Avoid steroids unless there is hypoxia
2) When indicated, use steroids at right dose and right duration.
3) Check & control blood sugars
4) Avoid antibiotics
There will be hardly anyone who gets mucor without at least one of these 4 factors.

Sure there may be something else going on in addition because we do have a lot people taking steroids and antibiotics for other reasons, and people who have diabetes who hardly ever get mucor.
But it will take time to investigate these additional factors and see if they can be fixed.

If someone is urgently in need of oxygen now, you have to give whatever oxygen is available. No choice. But you could control sugars, and use steroids at right dose for right duration.
Read 4 tweets
Vincent Rajkumar Profile picture
23 May
Just heard from @spkalantri that fully vaccinated healthcare workers are getting COVID in their institution @_mgims in India, but cases have all been mild. #VaccinesWork @paimadhu @soutikBBC

India needs a lot of help with vaccines to get over this crisis.
I am aware of anecdotes of fully vaccinated people get seriously ill and even die in India. But these are exceptions. Anecdotes don't give you a sense of the denominator. Exceptions will occur based on level of neutralizing antibody response & the vaccine used. See thread.
There is more on the protective effect of full vaccination against even the B1.617.2 variant in this thread by @jburnmurdoch
Read 4 tweets

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