The President's hospital stay continues through a third day, with conflicting messages on his health and an escalation in therapy.
The status of President Donald Trump’s hospitalization due to coronavirus 2019 (COVID-19) remains a conflict between a reported escalation of therapies and statements of assurance from his care team.
As of Saturday afternoon, Trump had been administered corticosteroid dexamethasone as part of his treatment regimen which has also included antiviral therapy remdesivir, and prior to both, an initiation of an investigative monoclonal antibody cocktail from Regeneron received upon a Compassionate Use request.
Sean P. Conley, DO, FACEP, Physician to the President, said on Sunday morning that the president was doing “really well” in the third day of his stay at Walter Reed National Military Medical Center, with plans to be discharged Monday morning.
Trump himself shared a video to his personal Twitter account late Saturday evening stating he is “starting to feel good,” praising the therapy regimen he had received in care thus far.
“We don’t know, over the next period of a few days, and I guess that’s the real test, so we’ll be seeing what happens over those next couple of days,” he said.
However, Conley also stated during a press briefing Sunday that Trump’s oxygen saturation had dropped twice since being first diagnosed with COVID-19 earlier this week, and prior to his admission at Walter Reed, the president had been observed to have a high fever and was provided supplemental oxygen.
When asked about signs of pneumonia from tests and scans, Conley stated the care team observed “expected findings but nothing of any major clinical concern.”
Remdesivir has been planned as a five-day regimen, according to the care team, which can be continued regardless of his stay at Walter Reed.
In phase 3 data published in JAMA Network last month, a five-day course of the antiviral therapy plus standard-of-care was associated with a statistically significant improved mean clinical status after 11 days (on a seven-point scale of severity from death to hospital discharge) versus lone standard-of-care among hospitalized patients with COVID-19.
However, such findings were observed in participants of varying age groups, and those with an ability to maintain oxygen saturation ≥94%. The president, 74 years old, was reported to have an oxygen saturation level of 93% on Saturday—not technically low relative to severely ill COVID-19 patients, but a decrease nonetheless.
In an editorial accompanying the recent remdesivir findings, Erin K. McCreary, PharmD, and Derek C. Angus, MD, MPH, of the UPMC Health System and The University of Pittsburgh School of Medicine, wrote that mixed results observed in a trio of late-stage randomized, controlled trials (RCTs) for remdesivir in hospitalized patients raises questions surrounding study design choices, tested patient populations, or even the efficacy of the drug itself.
“It therefore seems prudent to urgently conduct further evaluations of remdesivir in large-scale RCTs designed to address the residual uncertainties and inform optimal use,” they wrote.
And while early results from late-stage assessment of add-on corticosteroid use in severely ill COVID-19 patients has shown benefit in reduced mortality risk, recent discussion of surrounding agents including dexamethasone have challenged the role of inclusion in the magnitude of association between corticosteroids and mortality risk.
Upon hearing about Trump’s dexamethasone regimen Sunday, infectious disease experts including Craig Spencer, MD, MPH, Director of Global Health in Emergency Medicine at Columbia University Irving Medical Center, raised questions about its use relative to his reported care thus far.
So dexamethasone was found to be beneficial ONLY in patients on a ventilator OR on oxygen.
NOT on patients who don't need oxygen.
There was even the possibility of harm in that patient population.
— Craig Spencer MD MPH (@Craig_A_Spencer) October 4, 2020
Vin Gupta, MD, MPA, MSc, Affiliate Assistant Professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington and analyst for NBC and MSNBC, challenged the limited information provided by Conley on the president’s scans for pneumonia based on Trump’s regimen.
You don’t start dexamethasone, Remdesivir and given an experimental antibody cocktail to the President in the setting of low oxygen “dips” unless there’s COVID Pneumonia.
What did his chest imaging show? The American people deserve basic information on their President
— Vin Gupta “😷!” MD (@VinGuptaMD) October 4, 2020
Of course, there is unlikely any case study of COVID-19 to be scrutinized more than that of the President of the United States—a notion which Conley conceded in his briefing Sunday.
"As with any illness, there are frequent ups and downs, particularly when a patient is being so closely watched 24 hours a day,” he said.