Swinging the pendulum: lessons learned from public discourse concerning hydroxychloroquine and COVID-19

A population-based analysis of rheumatology care patterns for inflammatory arthritis during COVID-19 in Alberta, Canada

OBJECTIVE

The aim of the study was to understand the impact of the COVID-19 pandemic on inflammatory arthritis (IA) rheumatology care in Alberta, Canada.

METHODS

We used linked provincial health administrative datasets to establish an incident cohort of individuals with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and Ankylosing Spondylitis (AS) seen at least once by a rheumatologist. We examined incidence rates (IR) per 100,000 population, and patterns of follow-up care between 2011 and 2022. In a subset of individuals diagnosed five years prior to the pandemic, we report on those lost to follow-up during the pandemic, and those with virtual care visits followed by in-person visit within 30 days. Multivariable logistic regression was used to examine patient characteristics associated with these patterns of care.

RESULTS

The IR for RA in 2020 declined compared to previous years (44.6), but not for AS (9.2) or PsA (9.1). In 2021 IRs rose (RA 49.5; AS 11.8; PsA 11.8). Among those diagnosed within 5 years of the pandemic, 632 (6.0 %) were lost to follow-up, with characteristics of those lost to follow-up differing between IA types. 1444 individuals had at least one virtual visit followed within 30 days by an in-person follow-up. This was less common in males (OR 0.69-0.79) and more common for those with a higher frequency of physician visits prior to the pandemic (OR 1.27-1.32).

CONCLUSION

Impacts of patterns of care during the pandemic should be further explored for healthcare planning to uphold optimal care access and promote effective use of virtual care.

'Are you vaccinated? Yeah, I'm immunized': a risk orders theory analysis of celebrity COVID-19 misinformation

BACKGROUND

On 11 March 2020, COVID-19 was declared a global health pandemic by the World Health Organization (WHO). Vaccinating populations is paramount in changing the course of a pandemic. The rapid spread of (mis) and disinformation online from celebrities, politicians, and media influencers creates a corrosion of trust in public health interventions.

METHODS

Given the importance of the spread of information during a public health crisis, the current study uses risk orders theory with a constructivist grounded theory approach to analyze an episode of a popular podcast available on YouTube, titled, 'Aaron Rodgers Tells Pat McAfee His Side of Vaccine Situation.'

RESULTS

Findings illuminated three themes concerning COVID-19 medical interventions from celebrity discourse: (1) misinterpreting medical terminology; (2) conflating bodily autonomy and altruism; and (3) political ideology as an impetus for misinformation.

CONCLUSIONS

The discussion offers implications for healthcare practitioners in debunking mis- and disinformation. Foremost, lack of transparency concerning autonomy, liberty, freedom, and choice from public health experts who design messages during a public health crisis creates a space for non-medical influencers to promote pseudoscience, misinformation, and disinformation. This leads to public distrust of medical experts and confuses the public's understanding of best practices based upon standard of medical evidence and care.

An Electronic Dashboard to Improve Dosing of Hydroxychloroquine Within the Veterans Health Care System: Time Series Analysis

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used for patients with autoimmune conditions. Long-term use of HCQ can cause retinal toxicity, but this risk can be reduced if high doses are avoided.

OBJECTIVE

We developed and piloted an electronic health record-based dashboard to improve the safe prescribing of HCQ within the Veterans Health Administration (VHA). We observed pilot facilities over a 1-year period to determine whether they were able to improve the proportion of patients receiving inappropriate doses of HCQ.

METHODS

Patients receiving HCQ were identified from the VHA corporate data warehouse. Using PowerBI (Microsoft Corp), we constructed a dashboard to display patient identifiers and the most recent HCQ dose and weight (flagged if ≥5.2 mg/kg/day). Six VHA pilot facilities were enlisted to test the dashboard and invited to participate in monthly webinars. We performed an interrupted time series analysis using synthetic controls to assess changes in the proportion of patients receiving HCQ ≥5.2 mg/kg/day between October 2020 and November 2021.

RESULTS

At the start of the study period, we identified 18,525 total users of HCQ nationwide at 128 facilities in the VHA, including 1365 patients at the 6 pilot facilities. Nationwide, at baseline, 19.8% (3671/18,525) of patients were receiving high doses of HCQ. We observed significant improvements in the proportion of HCQ prescribed at doses ≥5.2 mg/kg/day among pilot facilities after the dashboard was deployed (-0.06; 95% CI -0.08 to -0.04). The difference in the postintervention linear trend for pilot versus synthetic controls was also significant (-0.06; 95% CI -0.08 to -0.05).

CONCLUSIONS

The use of an electronic health record-based dashboard reduced the proportion of patients receiving higher than recommended doses of HCQ and significantly improved performance at 6 VHA facilities. National roll-out of the dashboard will enable further improvements in the safe prescribing of HCQ.

A mixed methods study exploring requests for unproven COVID therapies such as ivermectin and healthcare distrust in the rural South

The COVID-19 pandemic has led to contentious discourse regarding unproven COVID-19 therapies (UCTs),(e.g. ivermectin). Despite recommendations against it, ivermectin remains, in some areas, highly demanded. The goal of this study is to understand patient and provider perspectives about UCTs (e.g., ivermectin) and how responses to requests for UCTs impact healthcare distrust. This mixed methods observational study was conducted in a rural healthcare system in the Southern United States. Adults (n = 26) with a history of COVID-19 or clinicians (n = 8) from the same system were interviewed using questionnaires assessing healthcare distrust and qualitatively interviewed exploring perceptions about UCTs. Patient themes were: 1) Importance of anecdotal stories for decision-making; 2) Use of haphazard approaches to 'research'; 3) Strong distrust of government and healthcare organizations; 4) Inherent trust in local healthcare; 5) Decision-making as weighing pros/cons; and 6) Feeling a right to try medications. High survey medians indicated high distrust with differences of 8.5 points for those who requested/used ivermectin versus those who did not (p = 0.027). Clinician themes were: 1) Frustration when patients trust social media over clinicians; 2) Acceptance of community beliefs about UCTs; 3) Distrust originating outside of the healthcare system; 4) Feeling torn about prescribing UCTs to build trust; and 5) Variable educational strategies. When clinicians are perceived as aligned with government, this may void patients' trust of clinicians. Clinicians should leverage trust in local healthcare and distance themselves from distrusted information sources. Ethical questions arise regarding appropriateness of acquiescing to patient requests for ivermectin for building trust.

Analysis of the Prophylactic use of Hydroxychloroquine at the Beginning of the COVID-19 Pandemic Among Physicians

Objective

Throughout the pandemic, physicians working at the frontlines have embarked on various quests to protect themselves, and many physicians preferred using hydroxychloroquine (HQN) as a prophylactic agent. This study aimed to investigate the reasons leading physicians to use HQN and its effects on them.

Materials and Methods

This study is cross-sectional with a target population of physicians working in pandemic hospitals in İstanbul, Turkey. We invited participants from seven hospitals via email between May 14 and June 13, 2020. An online questionnaire, including 57 questions, was sent to physicians.

Results

A total of 148 (26%) physicians out of 564 participants had used hydroxychloroquine for prevention. Older physicians and those with a history of exposure to COVID-19 patients without protection used prophylactic HQN more frequently. The use of HQN did not differ statistically in terms of being infected among the exposed physicians (p=0.52). Nineteen (13%) physicians using HQN developed side effects related to the drug. Diarrhea and nausea were the most common.

Conclusion

Prophylactic HQN use was more common among physicians older than 40 years and with higher exposure rates to a COVID-19 patient without protection. The physicians working on the front line had the highest rate of infection. HQN was not effective in the prophylaxis of COVID-19 among the exposed physicians.

Social Media for Research Discourse, Dissemination, and Collaboration in Rheumatology

Social media has become an important venue for rheumatologists, patients, organizations, and other stakeholders to discuss recent research advances in diagnosis and management of rheumatic disorders. In this article, we describe the current state of how social media may enhance dissemination, discourse, and collaboration in rheumatology research. Social media may refer to social platforms like Twitter and Instagram or digital media like podcasts and other websites that are operated for providing as free, open-access medical education (FOAM). Twitter has been one of the most active social media venues and continues to host a vibrant rheumatology community. Examples of research discussions on Twitter include organic user tweets, educational threads ("tweetorials"), live-tweeting academic conferences, and journals posting recently-accepted articles. Some research collaborations have been initiated through social media interactions. Social media may also directly contribute to research by facilitating the recruitment of study participants and the collection of survey-based data. Thus, social media is an evolving and important tool to enhance research discourse, dissemination, and collaboration in rheumatology.

Prevalence of coronavirus disease 2019 in a multiethnic cohort of patients with autoimmune rheumatic diseases in Qatar

BACKGROUND

Autoimmune rheumatic diseases (ARDs) are characterized by immune dysfunction and associated with an increased risk of infections, which were of significant concern during the coronavirus disease 2019 (COVID-19) pandemic. Variable rates of COVID-19 incidence have been reported in patients with ARDs; however, the true effect of this infection on this patient population is still unclear. We, therefore, aimed to evaluate the COVID-19 prevalence among a multiethnic cohort of patients with ARDs in Qatar.

MATERIAL AND METHODS

We used telephonic surveys to collect demographic and clinical information of patients with ARD in Qatar between April 1 and July 31, 2020, including any close contact with a COVID-19 case at home or work and polymerase chain reaction (PCR)-confirmed COVID-19 diagnosis. An electronic medical records review was conducted to verify pertinent data collected through the surveys. Prevalence with 95% confidence interval (CI), Student's t-tests, and chi-square/Fisher's exact tests were used for univariate analyses, whereas multivariate logistic regression was used to identify factors associated with COVID-19.

RESULTS

The study included 700 patients with ARD (mean age, 43.2 ± 12.3 years), and 73% were female. Until July 2020, 75 (11%, 95% CI 9%-13%) patients had COVID-19. Factors associated with COVID-19 included being a man (adjusted odds ratio [aOR] 2.56, 95% CI 1.35-4.88, p = 0.01) and having close contact with a COVID-19 case (aOR 27.89, 95% CI 14.85-52.38, p = 0.01). Disease severity and rheumatic medications had no significant association with the odds of contracting COVID-19. In the 86 patients with ARD having close contact, the frequency of hydroxychloroquine utilization was lower in patients who contracted COVID-19 than in those who did not (35% vs 72.5%, p = 0.01).

CONCLUSIONS

In Qatar, patients with ARDs had an overall higher prevalence of COVID-19 than global estimates. Being male and having close contact with a COVID-19 case were strongly associated with COVID-19 as reported globally. The presence of comorbid conditions, disease-specific factors, and rheumatic medications had no significant effect on the risk of COVID-19 in our study suggesting alternative mechanisms to the increased prevalence.

Psychosocial and clinical impact of COVID-19 pandemic and its relationship to the quality of life in patients with rheumatoid arthritis: a cross-sectional study, Egypt

Background

Data have been pouring on the impact of the COVID-19 pandemic on patients with chronic diseases. This study aimed to address the relationship between the perceived fears of COVID-19 virus (FCV), psychological status, and quality of life (QoL) among patients with rheumatoid arthritis (RA) during the pandemic. This study included 100 patients with RA and an equal number of control subjects, who were recruited from Zagazig University rheumatology outpatient clinics, Egypt. All subjects were interviewed using the fear of COVID-19 scale (FCV-19S), Symptom Checklist-90 scale (SCL-90), and World Health Organization Quality of Life Scale (WHOQOL-BREF). Patients were additionally assessed using the Disease Activity Score 28 (DAS28) and Modified Health Assessment Questionnaire (MHAQ).

Results

There were significant differences between both groups in all QoL domains and most psychological dimensions. Most patients with RA experienced moderate-to-high disease activity and mild-to-moderate functional impairment (85% and 80%, respectively). FCV was correlated with the number of family members (P-value 0.020), and obsessive-compulsive (P-value 0.006), interpersonal sensitivity (P-value 0.035), hostility (P-value 0.017), phobia (P-value 0.010), and psychoticism (P-value 0.034) symptoms. Moderate-to-high disease activity was associated with reduced psychological QoL. Patients with moderate-to-severe functional impairment had worse QoL in all domains (except social). Prolonged illness duration was associated with worse social QoL.

Conclusions

QoL was adversely affected in patients with RA during the pandemic. There was a robust relationship between FCV and the emergence of psychological symptoms. RA-related clinical factors like illness duration, disease activity, and functional disability were associated with reduced QoL in those patients.

The Promises and Perils of Social Media for Pediatric Rheumatology

The advent of social media has revolutionized and empowered communities of people living with rare diseases. Social media has enabled families of children with similar pediatric rheumatic diseases (PRDs) to meet regardless of geographic distance, allowing them to support each other and join together to advocate on behalf of their children. Researchers have also leveraged social media to learn about the health of patients and their communities. This article reviews the promises and perils of social media related to health, focusing on its potential use to support research and care of children with PRD.

Outside any therapeutic trial prescription of hydroxychloroquine for hospitalized patients with covid-19 during the first wave of the pandemic: A national inquiry of prescription patterns among French hospitalists

INTRODUCTION

During the first wave of the coronavirus-disease 2019 (covid-19) pandemic in early 2020, hydroxychloroquine (HCQ) was widely prescribed in light of in vitro activity against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Our objective was to evaluate in early 2020 the rate of French hospitalists declaring having prescribed HCQ to treat covid-19 patients outside any therapeutic trial, compare the reasons and the determinants for having prescribed HCQ or not.

MATERIAL AND METHODS

A national inquiry submitted by email from May 7 to 25, 2020, to a sample of French hospitalists: doctors managing patients hospitalized for covid-19 in a French department of internal medicine or infectious diseases and identified in the directories of French hospitals or as a member of the French Infectious Diseases Society (SPILF). Primary outcome was the percentage of hospitalists declaring having prescribed HCQ to covid-19 patients. Secondary outcomes were reasons and determinants of HCQ prescription.

RESULTS

Among 400 (22.8%) responding hospitalists, 45.3% (95% CI, 40.4 to 50.1%) declared having prescribed HCQ to covid-19 patients. Two main profiles were discerned: HCQ prescribers who did not raise its efficacy as a motive, and non-prescribers who based their decision on evidence-based medicine. Multivariate analysis retained the following prescription determinants (adjusted odds ratio; 95% confidence interval): a departmental procedure for HCQ prescription (8.25; 4.79 to 14.20), having prescribed other treatments outside a therapeutic trial (3.21; 1.81 to 5.71), prior HCQ prescription (2.75; 1.5 to 5.03) and HCQ prescribed within the framework of a therapeutic trial (0.56; 0.33 to 0.95).

CONCLUSION

Almost half of the hospitalists prescribed HCQ. The physician's personality (questioning or not evidence-based-medicine principles in the context of the pandemic) and departmental therapeutic procedures were the main factors influencing HCQ prescription. Establishment of "therapeutic" procedures represents a potential means to improve the quality of therapeutic decision-making during a pandemic.

Does the public know when a scientific controversy is over? Public perceptions of hydroxychloroquine in France between April 2020 and June 2021

Objectives

In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, chloroquine and its derivatives such as hydroxychloroquine (HCQ) were widely commented upon both within the scientific community and in the media. This paper explores the different factors that influenced public perceptions in France of the efficacy of HCQ as well as their evolution between April 2020 and June 2021.

Methods

This article draws on 5 surveys conducted among representative samples of the French population (projects COCONEL and TRACTRUST; quota method, n = 1006; 1004; 2006; 1014 and 1005). We asked questions on the effectiveness of chloroquine against COVID-19. We also collected sociodemographic variables and attitudes toward politics and science.

Results

Between April and June 2021, the proportion of respondents who believed in the efficacy of HCQ decreased rapidly from 35% to 14%. The proportion of respondents who believed that HCQ is ineffective rose gradually from 6% to 21%. After adjusting for the temporal effect, the logistic regression showed a very strong association between political orientation and the belief in the efficacy of HCQ. Respondents who felt closest to the more radical parties (far-right and far-left) were more likely to believe in the efficacy of HCQ than those who felt closest to the political center (O.R. 2.48 [1.95–3.15] and 1.87 [1.44–2.43]). The role of trust in the government and in science and of the degree of political engagement were investigated in the two waves conducted after the scientific consensus was established during the summer of 2020. High levels of trust in the government and in science and of politicization are associated with belief of HCQ proven inefficacy. Across the whole period, a majority of respondents were uncertain. Even in 2021, 41.5% stated that the data were insufficient to decide whether or not HCQ is effective and 25.2% stating that they did not know.

Conclusion

Because media coverage of scientific controversies is higher in times of uncertainty than after these controversies have died down, the publicization of therapeutic promises can have lasting consequences on attitudes towards science and medicine.

Formulating Hypotheses for Different Study Designs

Generating a testable working hypothesis is the first step towards conducting original research. Such research may prove or disprove the proposed hypothesis. Case reports, case series, online surveys and other observational studies, clinical trials, and narrative reviews help to generate hypotheses. Observational and interventional studies help to test hypotheses. A good hypothesis is usually based on previous evidence-based reports. Hypotheses without evidence-based justification and a priori ideas are not received favourably by the scientific community. Original research to test a hypothesis should be carefully planned to ensure appropriate methodology and adequate statistical power. While hypotheses can challenge conventional thinking and may be controversial, they should not be destructive. A hypothesis should be tested by ethically sound experiments with meaningful ethical and clinical implications. The coronavirus disease 2019 pandemic has brought into sharp focus numerous hypotheses, some of which were proven (e.g. effectiveness of corticosteroids in those with hypoxia) while others were disproven (e.g. ineffectiveness of hydroxychloroquine and ivermectin).

COVID-19 Prevalence and Outcomes among Individuals with Rheumatoid Arthritis and Systemic Lupus Erythematosus Taking Hydroxychloroquine; A Retrospective Analysis

Introduction:

The SARS-CoV-2 global pandemic has resulted in a universal search for potential treatments of Coronavirus Disease 2019 (COVID-19). Initial reports of the therapeutic potential of chloroquine (CQ) and hydroxychloroquine (HCQ) and early non-randomized non-controlled studies were followed by subsequent trials refuting such properties. The use of CQ and HCQ in diseases, such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), prompted us to examine the prevalence of COVID-19 and proposed prophylactic and therapeutic properties of HCQ in this population.

Methods:

A total of 103 patients with RA and SLE aged 18 to 75 diagnosed with COVID-19 were identified. The patients were categorized as those taking HCQ (cases) and those not on HCQ (controls) for at least 6 months. Primary (mechanical ventilation, length of stay, death) and secondary outcomes were defined, data were collected, and results were compared and statistically analyzed between cases and controls.

Results:

No statistical difference was observed in demographic features, baseline comorbidities, and medications. Primary outcomes’ statistical analysis did not reveal any differences between cases and controls. Statistical analysis of secondary outcomes revealed that cases had a statistically higher chance of being tachypneic (p 0.034). D-Dimer (p 0.017) and LDH levels (p 0.044) were found to be significantly lower in cases versus controls.

Conclusion:

This study highlights the lack of clinical prophylactic and therapeutic efficacy of HCQ against COVID-19 when taken at regular doses for patients with RA and SLE. It also shows that the prevalence of COVID-19 was similar in RA and SLE patients regardless of baseline consumption of HCQ.

Mental health in patients with rheumatic diseases related to COVID-19 pandemic: Experience in a tertiary care center in Latin America

OBJECTIVE

To determine the factors associated with anxiety, depression, and concern within the COVID-19 pandemic in a population with autoimmune diseases.

METHODS

A telephonic survey was conducted during the early stages of the pandemic in a tertiary care center, which included patients with systemic autoimmune diseases. Mental health variables were assessed with Patient Health Questionnaire 2, General Anxiety Disorder 7 scores, and pandemic-related concern questions. Sociodemographic aspects were also evaluated.

RESULTS

Of the total 334 participants, 291 (87.1%) were women, with a median age of 46 years; systemic lupus erythematosus (SLE) was the most frequent diagnosis (144, 43.2%); 44 patients (13.2%) showed depression and 32 (9.6%) anxiety. The variables associated with depression were all the pandemic concern items, body mass index, anxiety, and a higher COVID-19 symptom score. Anxiety was associated with depression, all pandemic concern items, and a higher COVID-19 symptom score. Women presented higher scores in all concern items. The SLE group presented higher scores in concern questions and difficulty finding medication.

CONCLUSION

During the COVID-19 outbreak, rheumatic patients are vulnerable to psychiatric conditions, which makes it imperative for physicians who treat these patients to pay careful attention in order to detect them promptly and to settle coping strategies.

Challenges of Egyptian patients with systemic lupus erythematosus during the COVID-19 pandemic

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic in Egypt is part of the worldwide COVID-19 pandemic that has contributed to substantial deterioration of healthcare systems. The aim of this study was to assess the challenges faced by Egyptian systemic lupus erythematosus (SLE) patients during the COVID-19 pandemic.

MATERIAL AND METHODS

This questionnaire-based study was carried out on 200 patients with SLE from Egypt. The questionnaire provided covered socioeconomic status, lupus disease data, information about COVID-19 infection, and medical and family history of COVID-19 infection.

RESULTS

The mean age of the participants was 30.1 ±8.4 years. 140/200 (70%) of the participants reported difficulty in obtaining medications during the COVID-19 pandemic, particularly antimalarials (60%). The lupus disease condition became worse because of the drug shortage in half of the participants. Wearing protective masks (74%) and using disinfectants of the hands several times per day (67%) were the most reported used measures. Forty patients (20%) had to stop or reduce taking nonsteroidal anti-inflammatory drugs while 10 patients (5%) had to start taking antimalarials as a prophylaxis against COVID-19 infection. Among those who needed hospitalization, the main cause was lupus activity, and most of them (71%) experienced difficulty in hospital admission. Thirty-two patients (16%) had confirmed COVID-19 infection. About half of them had lupus flare and had to change the medications used for treatment of lupus.

CONCLUSIONS

The current COVID-19 pandemic has a negative impact on the healthcare provided to SLE patients in Egypt. Patients with SLE faced a shortage of their medications, especially antimalarials, and difficulty in hospital admission.

Science's Response to CoVID-19

CoVID-19 is a multi-symptomatic disease which has made a global impact due to its ability to spread rapidly, and its relatively high mortality rate. Beyond the heroic efforts to develop vaccines, which we do not discuss herein, the response of scientists and clinicians to this complex problem has reflected the need to detect CoVID-19 rapidly, to diagnose patients likely to show adverse symptoms, and to treat severe and critical CoVID-19. Here we aim to encapsulate these varied and sometimes conflicting approaches and the resulting data in terms of chemistry and biology. In the process we highlight emerging concepts, and potential future applications that may arise out of this immense effort.

Trends in COVID-19 cases and clinical management in Veterans Health Administration medical facilities: A national cohort study

OBJECTIVE

We explored longitudinal trends in sociodemographic characteristics, reported symptoms, laboratory findings, pharmacological and non-pharmacological treatment, comorbidities, and 30-day in-hospital mortality among hospitalized patients with coronavirus disease 2019 (COVID-19).

METHODS

This retrospective cohort study included patients diagnosed with COVID-19 in the United States Veterans Health Administration between 03/01/20 and 08/31/20 and followed until 09/30/20. We focused our analysis on patients that were subsequently hospitalized, and categorized them into groups based on the month of hospitalization. We summarized our findings through descriptive statistics. We used Cuzick's Trend Test to examine any differences in the distribution of our study variables across the six months.

RESULTS

During our study period, we identified 43,267 patients with COVID-19. A total of 8,240 patients were hospitalized, and 13.1% (N = 1,081) died within 30 days of admission. Hospitalizations increased over time, but the proportion of patients that died consistently declined from 24.8% (N = 221/890) in March to 8.0% (N = 111/1,396) in August. Patients hospitalized in March compared to August were younger on average, mostly black, urban-dwelling, febrile and dyspneic. They also had a higher frequency of baseline comorbidities, including hypertension and diabetes, and were more likely to present with abnormal laboratory findings including low lymphocyte counts and elevated creatinine. Lastly, there was a decline from March to August in receipt of mechanical ventilation (31.4% to 13.1%) and hydroxychloroquine (55.3% to <1.0%), while treatment with dexamethasone (3.7% to 52.4%) and remdesivir (1.1% to 38.9%) increased.

CONCLUSION

Among hospitalized patients with COVID-19, we observed a trend towards decreased disease severity and mortality over time.

Open science saves lives: lessons from the COVID-19 pandemic

In the last decade Open Science principles have been successfully advocated for and are being slowly adopted in different research communities. In response to the COVID-19 pandemic many publishers and researchers have sped up their adoption of Open Science practices, sometimes embracing them fully and sometimes partially or in a sub-optimal manner. In this article, we express concerns about the violation of some of the Open Science principles and its potential impact on the quality of research output. We provide evidence of the misuses of these principles at different stages of the scientific process. We call for a wider adoption of Open Science practices in the hope that this work will encourage a broader endorsement of Open Science principles and serve as a reminder that science should always be a rigorous process, reliable and transparent, especially in the context of a pandemic where research findings are being translated into practice even more rapidly. We provide all data and scripts at https://osf.io/renxy/ .

COVID-19 and the generation of novel scientific knowledge: Research questions and study designs

RATIONALE, AIMS, AND OBJECTIVES

One of the sectors challenged by the COVID-19 pandemic is medical research. COVID-19 originates from a novel coronavirus (SARS-CoV-2) and the scientific community is faced with the daunting task of creating a novel model for this pandemic or, in other words, creating novel science. This paper is the first part of a series of two papers that explore the intricate relationship between the different challenges that have hindered biomedical research and the generation of scientific knowledge during the COVID-19 pandemic.

METHODS

During the early stages of the pandemic, research conducted on hydroxychloroquine (HCQ) was chaotic and sparked several heated debates with respect to the scientific methods used and the quality of knowledge generated. Research on HCQ is used as a case study in both papers. The authors explored biomedical databases, peer-reviewed journals, pre-print servers, and media articles to identify relevant literature on HCQ and COVID-19, and examined philosophical perspectives on medical research in the context of this pandemic and previous global health challenges.

RESULTS

This paper demonstrates that a lack of prioritization among research questions and therapeutics was responsible for the duplication of clinical trials and the dispersion of precious resources. Study designs, aimed at minimising biases and increasing objectivity, were, instead, the subject of fruitless oppositions. The duplication of research works, combined with poor-quality research, has greatly contributed to slowing down the creation of novel scientific knowledge.

CONCLUSIONS

The COVID-19 pandemic presented challenges in terms of (1) finding and prioritising relevant research questions and (2) choosing study designs that are appropriate for a time of emergency.

Use of hydroxychloroquine and chloroquine in patients with COVID-19: a meta-analysis of randomized clinical trials

COVID-19 has quickly become a public health problem worldwide, and treatment for this new disease is needed. Hydroxychloroquine is an antimalarial that in vitro studies have shown action against SARS-CoV-2, which is why it has been the target of clinical studies with conflicting results. Therefore, the aim of this systematic review was to assess the association of hydroxychloroquine use with the virological cure, clinical recovery, mortality, and development of adverse effects in patients with COVID-19. PubMed, Cochrane Library, and Lilacs were searched until 7 January 2021, for randomized clinical trials with COVID-19 patients treated with hydroxychloroquine or chloroquine. Of the 130 studies found, 12 met the inclusion criteria. Compared to the patient's control group, the risk ratio (RR) for the virological cure and clinical recovery with hydroxychloroquine or chloroquine use was 1.04 (95%CI 0.91-1.17) and 1.03 (95%CI 0.92-1.13), respectively. Hydroxychloroquine (with or without azithromycin) was also not associated with mortality (RR = 1.09, 95%CI 0.98-1.20). Treatment with hydroxychloroquine was associated with any adverse effects (RR = 1.50, 95%CI 1.18-1.81). Hydroxychloroquine or chloroquine use did not have a significant effect on virological cure, the time of clinical recovery, and improvement in survival in COVID-19 patients. However, patients who used hydroxychloroquine showed an increase in adverse effects.

COVID-19 and rheumatoid arthritis

PURPOSE OF REVIEW

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. Patients with rheumatoid arthritis (RA) face unique challenges during the pandemic, including concerns regarding infection risk, drug shortages, limited access to care, social isolation, and mental health. This review will examine the multifaceted impacts of the COVID-19 pandemic on patients living with RA.

RECENT FINDINGS

In patients with RA, risk factors for severe COVID-19 outcomes include older age and comorbidities, similar to those in the general population. Glucocorticoids, but not other classes of disease-modifying antirheumatic drugs (DMARDs), appear to be associated with a higher risk of severe COVID-19 outcomes. RA patients have been affected by changes in access to care, telemedicine, drug shortages, anxiety, and social isolation, which may contribute to disease flares.

SUMMARY

Glucocorticoids, but not other DMARDs, are associated with a higher risk of severe COVID-19 outcomes in RA patients. Further studies are needed to explore the impact of specific DMARDs on COVID-19 outcomes, understand the broader implications of the COVID-19 pandemic on RA disease activity, and optimize the use of telemedicine in RA management.

COVID-19 and Disease-Modifying Anti-rheumatic Drugs

PURPOSE OF REVIEW

Patients on disease-modifying anti-rheumatic drugs (DMARDs) remain concerned about potential risks of severe COVID-19 outcomes. Meanwhile, several DMARDs have been proposed as COVID-19 therapies.

RECENT FINDINGS

In patients with autoimmune diseases, baseline glucocorticoid use is associated with severe COVID-19. While classes of DMARDs (e.g., conventional synthetic, targeted synthetic, and biologic) do not appear to be associated with higher risk, specific medications such as rituximab and sulfasalazine may be associated. Randomized clinical trials (RCTs) show that glucocorticoids reduce mortality in severe COVID-19. RCTs suggest other agents, such as baricitinib, may improve COVID-19 outcomes in certain populations. Baseline glucocorticoid use raises the risk of severe COVID-19 in patients with autoimmune diseases, but glucocorticoids are an effective treatment for those with severe COVID-19. Further research is needed to inform DMARD management in autoimmune disease patients during the pandemic and the role of DMARDs in COVID-19 treatment.

The Surviving Sepsis Campaign: Research Priorities for Coronavirus Disease 2019 in Critical Illness

OBJECTIVES

To identify research priorities in the management, pathophysiology, and host response of coronavirus disease 2019 in critically ill patients.

DESIGN

The Surviving Sepsis Research Committee, a multiprofessional group of 17 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine, was virtually convened during the coronavirus disease 2019 pandemic. The committee iteratively developed the recommendations and subsequent document.

METHODS

Each committee member submitted a list of what they believed were the most important priorities for coronavirus disease 2019 research. The entire committee voted on 58 submitted questions to determine top priorities for coronavirus disease 2019 research.

RESULTS

The Surviving Sepsis Research Committee provides 13 priorities for coronavirus disease 2019. Of these, the top six priorities were identified and include the following questions: 1) Should the approach to ventilator management differ from the standard approach in patients with acute hypoxic respiratory failure?, 2) Can the host response be modulated for therapeutic benefit?, 3) What specific cells are directly targeted by severe acute respiratory syndrome coronavirus 2, and how do these cells respond?, 4) Can early data be used to predict outcomes of coronavirus disease 2019 and, by extension, to guide therapies?, 5) What is the role of prone positioning and noninvasive ventilation in nonventilated patients with coronavirus disease?, and 6) Which interventions are best to use for viral load modulation and when should they be given?

CONCLUSIONS

Although knowledge of both biology and treatment has increased exponentially in the first year of the coronavirus disease 2019 pandemic, significant knowledge gaps remain. The research priorities identified represent a roadmap for investigation in coronavirus disease 2019.

French Public Familiarity and Attitudes toward Clinical Research during the COVID-19 Pandemic

The COVID-19 pandemic put clinical research in the media spotlight globally. This article proposes a first measure of familiarity with and attitude toward clinical research in France. Drawing from the “Health Literacy Survey 2019” (HLS19) conducted online between 27 May and 5 June 2020 on a sample of the French adult population (N = 1003), we show that a significant proportion of the French population claimed some familiarity with clinical trials (64.8%) and had positive attitudes (72%) toward them. One of the important findings of this study is that positive attitudes toward clinical research exist side by side with a strong distancing from the pharmaceutical industry. While respondents acknowledged that the pharmaceutical industry plays an important role in clinical research (68.3%), only one-quarter indicated that they trust the industry (25.7%). Positive attitudes toward clinical trials were associated with familiarity with clinical trials (Odds Ratio, OR 2.97 [1.90–4.63]), financial difficulties (OR 0.63 [0.46–0.85]), as well as mistrust of doctors (0.48 [0.27–0.85]) and of scientists (OR 0.62 [0.38–0.99]). Although the French media provided a great deal of information on how clinical research works during the first months of the pandemic, there remains profound mistrust of the pharmaceutical industry in France. This suspicion can undermine crisis management, especially in the areas of vaccine development and preparation for future pandemics.

Global research collaboration in a pandemic-challenges and opportunities: the COVID-19 Global Rheumatology Alliance

PURPOSE OF REVIEW

This review discusses the coronavirus disease-2019 (COVID-19) Global Rheumatology Alliance (GRA), the reason for its formation, the challenges with running the registry, and future opportunities for global collaborative research in rheumatology.

RECENT FINDINGS

The GRA has been successful in collecting and publishing a large volume of case data on patients with rheumatic disease with COVID-19. In addition, the GRA has published reviews, opinion pieces, and patient-directed summaries of research to further assist in disseminating timely and accurate information about COVID-19 in rheumatic diseases. There have been numerous challenges in the journey but they have been addressed through a collaborative problem-solving approach.

SUMMARY

The initial objectives of the GRA to describe the outcomes in patients with rheumatic disease who developed COVID-19 have been achieved. There has been extensive use of the data in the clinic and also to try and understand the mechanisms of disease and opportunities for drug repurposing. There remain numerous important areas for research which the GRA will continue to pursue as the pandemic evolves.

Let’s do better: public representations of COVID-19 science

COVID science is being both done and circulated at a furious pace. While it is inspiring to see the research community responding so vigorously to the pandemic crisis, all this activity has also created a churning sea of bad data, conflicting results, and exaggerated headlines. With representations of science becoming increasingly polarized, twisted, and hyped, there is growing concern that the relevant science is being represented to the public in a manner that may cause confusion, inappropriate expectations, and the erosion of public trust. Here we explore some of the key issues associated with the representations of science in the context of the COVID-19 pandemic. Many of these issues are not new. But the COVID-19 pandemic has placed a spotlight on the biomedical research process and amplified the adverse ramifications of poor public communication. We need to do better. As such, we conclude with 10 recommendations aimed at key actors involved in the communication of COVID-19 science, including government, funders, universities, publishers, media, and the research communities.

Clinical pathways for patients with giant cell arteritis during the COVID-19 pandemic: an international perspective

Giant cell arteritis, a common primary systemic vasculitis affecting older people, presents acutely as a medical emergency and requires rapid specialist assessment and treatment to prevent irreversible vision loss. Disruption of the health-care system caused by the COVID-19 pandemic exposed weak points in clinical pathways for diagnosis and treatment of giant cell arteritis, but has also permitted innovative solutions. The essential roles played by all professionals, including general practitioners and surgeons, in treating these patients have become evident. Patients must also be involved in the reshaping of clinical services. As an international group of authors involved in the care of patients with giant cell arteritis, we reflect in this Viewpoint on rapid service adaptations during the first peak of COVID-19, evaluate challenges, and consider implications for the future.

Hydroxychloroquine for the treatment of COVID-19 and its potential cardiovascular toxicity: Hero or villain?

A variety of treatment modalities have been investigated since the beginning of the Coronavirus Disease-19 (COVID-19) pandemic. The use of antimalarials (hydroxychloroquine and chloroquine) for COVID-19 treatment and prevention has proven to be a cautionary tale for widespread, off-label use of a medication during a crisis. The investigation of antimalarials for COVID-19 has also been a driver for a deluge of scientific output in a short amount of time. In this narrative review, we detail the evidence for and against antimalarial use in COVID-19, starting with the early small observational studies that influenced strategies worldwide. We then contrast these findings to later published larger observational studies and randomized controlled trials. We detail the emerging possible cardiovascular risks associated with antimalarial use in COVID-19 and whether COVID-19-related outcomes and cardiovascular risks may differ for antimalarials used in rheumatic diseases.

Causal inference methods for small non-randomized studies: Methods and an application in COVID-19

The usual development cycles are too slow for the development of vaccines, diagnostics and treatments in pandemics such as the ongoing SARS-CoV-2 pandemic. Given the pressure in such a situation, there is a risk that findings of early clinical trials are overinterpreted despite their limitations in terms of size and design. Motivated by a non-randomized open-label study investigating the efficacy of hydroxychloroquine in patients with COVID-19, we describe in a unified fashion various alternative approaches to the analysis of non-randomized studies. A widely used tool to reduce the impact of treatment-selection bias are so-called propensity score (PS) methods. Conditioning on the propensity score allows one to replicate the design of a randomized controlled trial, conditional on observed covariates. Extensions include the g-computation approach, which is less frequently applied, in particular in clinical studies. Moreover, doubly robust estimators provide additional advantages. Here, we investigate the properties of propensity score based methods including three variations of doubly robust estimators in small sample settings, typical for early trials, in a simulation study. R code for the simulations is provided.

Rise and Fall: Hydroxychloroquine and COVID-19 Global Trends: Interest, Political Influence, and Potential Implications

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to rapid research and reporting on potential preventatives and treatments for the disease, including the drug hydroxychloroquine (HCQ). Despite a lack of robust evidence to support the use of HCQ for treatment of COVID-19, it was publicly endorsed and received widespread media coverage and public interest. The purpose of this report is to describe and contextualize the surges in public interest, demand, and adoption of HCQ for treatment of COVID-19 and outline implications for future public health policy and practice.

METHODS

Using national and global events and Google Trends data as a measure of public interest, we describe the timeline and trends in the emergence of, interest in, and adoption of HCQ as a treatment of COVID-19. We additionally review reports on public demand for HCQ for treatment of COVID-19 and impacts on medication access among patients with indicated uses.

RESULTS

Public interest and demand for HCQ surged in the United States and globally following endorsements from public officials and enaction of policies to facilitate off-label use of HCQ for treatment of COVID-19. Surges in demand for HCQ led to multiple documented shortages and barriers to accessing HCQ treatment for patients with indicated uses for HCQ. Although there have been reversals in policies to support HCQ use for treatment of COVID-19 in some regions, others have continued or expanded recommended uses.

CONCLUSION

Insights from the global response to HCQ and COVID-19 can be used to inform prudent decision-making in the future to prevent premature action and promote informed and equitable responses to promote public health.

Questions and Answers on Practical Thrombotic Issues in SARS-CoV-2 Infection: A Guidance Document from the Italian Working Group on Atherosclerosis, Thrombosis and Vascular Biology

In patients with coronavirus disease 2019 (COVID-19), the prevalence of pre-existing cardiovascular diseases is elevated. Moreover, various features, also including pro-thrombotic status, further predispose these patients to increased risk of ischemic cardiovascular events. Thus, the identification of optimal antithrombotic strategies in terms of the risk-benefit ratio and outcome improvement in this setting is crucial. However, debated issues on antithrombotic therapies in patients with COVID-19 are multiple and relevant. In this article, we provide ten questions and answers on risk stratification and antiplatelet/anticoagulant treatments in patients at risk of/with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on the scientific evidence gathered during the pandemic.

Hydroxychloroquine and COVID-19: Lack of Efficacy and the Social Construction of Plausibility

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 SARS- Cov2 has taken the world by surprise. Among the first promising repurposing agents proposed for treatment and prophylaxis, 2 antimalarial agents came into limelight: chloroquine and its less toxic derivative, hydroxychloroquine (HCQ). Intense research and public debates have followed.

AREAS OF UNCERTAINTY

As HCQ is still used and studied, future research may bring novel evidence, modifying the state-of-the-art. Despite the lack of a single randomized control trial (RCT) with positive results, there are currently (as for the search on 30th of August 2020) more than 250 RCT registered on ClinicalTrials.gov with HCQ in COVID patients, and more than 150 of them are "still recruiting" or "not yet recruiting" patients.

DATA SOURCES

Our study combines a therapeutic evaluation of RCT data with a sociological analysis of related controversies, examining scientific and public arena discourses.

RESULTS

Although any hope of a positive effect was brought exclusively by some and not all of the observational studies, none of the 7 RCT published until now have found any benefit. From a sociological perspective, the HCQ controversy is a useful case study for understanding the construction of plausibility in a cultural context polarized into competing versions of reality, with different epistemologies and ideologies.

CONCLUSIONS

The results of the first RCTs have been published, and they are disappointing; beneficial effects of HCQ could not be proven either for negative conversion on polymerase chain reactions of COVID patients or for postexposure prophylaxis. The question to be asked is: how many studies do we need until HCQ is abandoned? Argumentative time work, appealing to temporal properties of HCQ including its historical use, accumulation of evidence, alternative therapeutic scenarios, and sensationalist tempo for rhetorical purpose, plays a significant role in its continuing legitimation.

Data monitoring committees for clinical trials evaluating treatments of COVID-19

The first cases of coronavirus disease 2019 (COVID-19) were reported in December 2019 and the outbreak of SARS-CoV-2 was declared a pandemic in March 2020 by the World Health Organization. This sparked a plethora of investigations into diagnostics and vaccination for SARS-CoV-2, as well as treatments for COVID-19. Since COVID-19 is a severe disease associated with a high mortality, clinical trials in this disease should be monitored by a data monitoring committee (DMC), also known as data safety monitoring board (DSMB). DMCs in this indication face a number of challenges including fast recruitment requiring an unusually high frequency of safety reviews, more frequent use of complex designs and virtually no prior experience with the disease. In this paper, we provide a perspective on the work of DMCs for clinical trials of treatments for COVID-19. More specifically, we discuss organizational aspects of setting up and running DMCs for COVID-19 trials, in particular for trials with more complex designs such as platform trials or adaptive designs. Furthermore, statistical aspects of monitoring clinical trials of treatments for COVID-19 are considered. Some recommendations are made regarding the presentation of the data, stopping rules for safety monitoring and the use of external data. The proposed stopping boundaries are assessed in a simulation study motivated by clinical trials in COVID-19.

Investigating the Prevalence of Reactive Online Searching in the COVID-19 Pandemic: Infoveillance Study

BACKGROUND

The ongoing pandemic has placed an unprecedented strain on global society, health care, governments, and mass media. Public dissemination of government policies, medical interventions, and misinformation has been remarkably rapid and largely unregulated during the COVID-19 pandemic, resulting in increased misinterpretations, miscommunication, and public panic. Being the first full-scale global pandemic of the digital age, COVID-19 has presented novel challenges pertinent to government advice, the spread of news and misinformation, and the trade-off between the accessibility of science and the premature public use of unproven medical interventions.

OBJECTIVE

This study aims to assess the use of internet search terms relating to COVID-19 information and misinformation during the global pandemic, identify which were most used in six affected countries, investigate any temporal trends and the likely propagators of key search terms, and determine any correlation between the per capita cases and deaths with the adoption of these search terms in each of the six countries.

METHODS

This study uses relative search volume data extracted from Google Trends for search terms linked to the COVID-19 pandemic alongside per capita case and mortality data extracted from the European Open Data Portal to identify the temporal dynamics of the spread of news and misinformation during the global pandemic in six affected countries (Australia, Germany, Italy, Spain, the United Kingdom, and the United States). A correlation analysis was carried out to ascertain any correlation between the temporal trends of search term use and the rise of per capita mortality and disease cases.

RESULTS

Of the selected search terms, most were searched immediately following promotion by governments, public figures, or viral circulation of information, but also in relation to the publication of scientific resources, which were sometimes misinterpreted before further dissemination. Strong correlations were identified between the volume of these COVID-19-related search terms (overall mean Spearman rho 0.753, SD 0.158), and per capita mortality (mean per capita deaths Spearman rho 0.690, SD 0.168) and cases (mean per capita cases Spearman rho 0.800, SD 0.112).

CONCLUSIONS

These findings illustrate the increased rate and volume of the public consumption of novel information during a global health care crisis. The positive correlation between mortality and online searching, particularly in countries with lower COVID-19 testing rates, may demonstrate the imperative to safeguard official communications and dispel misinformation in these countries. Online news, government briefings, and social media provide a powerful tool for the dissemination of important information to the public during pandemics, but their misuse and the presentation of misrepresented medical information should be monitored, minimized, and addressed to safeguard public safety. Ultimately, governments, public health authorities, and scientists have a moral imperative to safeguard the truth and maintain an accessible discourse with the public to limit fear.

Clinical management of Lupus patients during the COVID-19 pandemic

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus causing Coronavirus disease 2019 (COVID-19), has had a huge impact on health services with a high mortality associated with complications including pneumonia and acute respiratory distress syndrome. Historical evidence suggests that Lupus patients have a higher incidence of several viral infections. This is likely due to a combination of immune dysfunction, immunosuppressive therapy and excess co-morbidities. In this context there has been concern that Lupus patients may be at a higher risk of developing COVID-19 and suffering a severe disease course. As a result, many Lupus patients have been advised to ‘shield’ by isolating from social contact in the hope that this will reduce the likelihood of infection. Early clinical data does not appear to show that the incidence of COVID-19 is higher in Lupus patients. Reassuringly, the clinical course of COVID-19 in Lupus does not generally seem to be more severe than in the general population. There has been huge interest in repurposing existing drugs as potential treatments, including several used to treat Lupus. Of these, corticosteroids and hydroxychloroquine are the most well researched so far. The current evidence suggests that the corticosteroid dexamethasone improves outcome for the sickest COVID-19 patients requiring respiratory support. Initial reports suggested that hydroxychloroquine could have a positive impact on the course of COVID-19, however larger prospective studies have not supported this. Janus kinase inhibitors, currently being investigated for efficacy in lupus, have been shown to have anti-viral effects in vitro and inhibiting the JAK-STAT pathway may dampen down the host hyper-inflammatory response. Several trials are ongoing to assess the outcome of the use of JAK inhibitors in COVID-19 positive patients. For most patients continuing with their existing therapies to prevent a lupus flare or adverse events associated with sudden corticosteroid withdrawal is important whilst an Individualised risk assessment remains vital.

#Covid4Rheum: an analytical twitter study in the time of the COVID-19 pandemic

Social media services, such as Twitter, offer great potential for a better understanding of rheumatic and musculoskeletal disorders (RMDs) and improved care in the field of rheumatology. This study examined the content and stakeholders associated with the Twitter hashtag #Covid4Rheum during the COVID-19 pandemic. The content analysis shows that Twitter connects stakeholders of the rheumatology community on a global level, reaching millions of users. Specifically, the use of hashtags on Twitter assists digital crowdsourcing projects and scientific collaboration, as exemplified by the COVID-19 Global Rheumatology Alliance registry. Moreover, Twitter facilitates the distribution of scientific content, such as guidelines or publications. Finally, digital data mining enables the identification of hot topics within the field of rheumatology.

Protocol for the DisCoVeRy trial: multicentre, adaptive, randomised trial of the safety and efficacy of treatments for COVID-19 in hospitalised adults

INTRODUCTION

To find effective and safe treatments for COVID-19, the WHO recommended to systemically evaluate experimental therapeutics in collaborative randomised clinical trials. As COVID-19 was spreading in Europe, the French national institute for Health and Medical Research (Inserm) established a transdisciplinary team to develop a multi-arm randomised controlled trial named DisCoVeRy. The objective of the trial is to evaluate the clinical efficacy and safety of different investigational re-purposed therapeutics relative to Standard of Care (SoC) in patients hospitalised with COVID-19.

METHODS AND ANALYSIS

DisCoVeRy is a phase III, open-label, adaptive, controlled, multicentre clinical trial in which hospitalised patients with COVID-19 in need of oxygen therapy are randomised between five arms: (1) a control group managed with SoC and four therapeutic arms with re-purposed antiviral agents: (2) remdesivir + SoC, (3) lopinavir/ritonavir + SoC, (4) lopinavir/ritonavir associated with interferon (IFN)-β-1a + SoC and (5) hydroxychloroquine + SoC. The primary endpoint is the clinical status at Day 15 on the 7-point ordinal scale of the WHO Master Protocol (V.3.0, 3 March 2020). This trial involves patients hospitalised in conventional departments or intensive care units both from academic or non-academic hospitals throughout Europe. A sample size of 3100 patients (620 patients per arm) is targeted. This trial has begun on 22 March 2020. Since 5 April 2020, DisCoVeRy has been an add-on trial of the Solidarity consortium of trials conducted by the WHO in Europe and worldwide. On 8 June 2020, 754 patients have been included.

ETHICS AND DISSEMINATION

Inserm is the sponsor of DisCoVeRy. Ethical approval has been obtained from the institutional review board on 13 March 2020 (20.03.06.51744) and from the French National Agency for Medicines and Health Products (ANSM) on 9 March 2020. Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04315948 Eudra-CT 2020-000936-23.

Benefits and adverse effects of hydroxychloroquine, methotrexate and colchicine: searching for repurposable drug candidates

Repurposing of antirheumatic drugs has garnered global attention. The aim of this article is to overview available evidence on the use of widely used antirheumatic drugs hydroxychloroquine, methotrexate and colchicine for additional indications. Hydroxychloroquine has endothelial stabilizing and anti-thrombotic effects. Its use has been explored as an adjunctive therapy in refractory thrombosis in antiphospholipid syndrome. It may also prevent recurrent pregnancy losses in the absence of antiphospholipid antibodies. Hydroxychloroquine favourably modulates atherogenic lipid and glycaemic profiles. Methotrexate has been tried for modulation of cardiovascular events in non-rheumatic clinical conditions, although a large clinical trial failed to demonstrate a benefit. Colchicine has been shown to successfully reduce the risk of recurrent cardiovascular events in a large multicentric trial. Potential antifibrotic effects of colchicine require further exploration. Hydroxychloroquine, methotrexate and colchicine are also being tried at different stages of the ongoing Coronavirus Disease 19 (COVID-19) pandemic for prophylaxis and treatment. While the use of these agents is being diversified, their adverse effects should be timely diagnosed and prevented. Hydroxychloroquine can cause retinopathy and rarely cardiac and auditory toxicity, retinopathy being dose and time dependent. Methotrexate can cause transaminitis, cytopenias and renal failure, particularly in acute overdoses. Colchicine can rarely cause myopathies, cardiomyopathy, cytopenias and transaminitis. Strong evidence is warranted to keep balance between benefits of repurposing these old antirheumatic drugs and risk of their adverse effects.

Treatment Options for Coronavirus Disease 2019 in Patients With Reduced or Absent Kidney Function

Coronavirus disease 2019, the disease caused by the severe acute respiratory syndrome coronavirus 2 virus, was first identified in the Hubei Province of China in late 2019. Currently, the only role for therapy is treatment of the disease, as opposed to postexposure prophylaxis, however multiple clinical trials are currently ongoing for both treatment and prophylaxis. Treating coronavirus disease 2019 relies on two components; the first is inhibition of the viral entrance and replication within the body and the second is inhibition of an exacerbated immune response which can be seen in patients with severe disease. Many drugs have shown in vitro antiviral activity; however, clinical trials have not been as promising. This review summarizes the current data for the most commonly used drugs for coronavirus disease 2019 and will cover the unique factors that may affect the dosing of these medications in patients with CKD. While clinical trials are ongoing, most are in patients with normal kidney function. During a pandemic, when patients with CKD are at higher risk of both infection and death, it is imperative to include patients these patients in the clinical trials.

Open drug discovery of anti-virals critical for Canada’s pandemic strategy

In the event of the current COVID-19 pandemic and in preparation for future pandemics, open science can support mission-oriented research and development, as well as commercialization. Open science shares skills and resources across sectors; avoids duplication and provides the basis for rapid and effective validation due to full transparency. It is a strategy that can adjust quickly to reflect changing incentives and priorities, because it does not rely on any one actor or sector. While eschewing patents, it can ensure high-quality drugs, low pricing, and access through existing regulatory mechanisms. Open science practices and partnerships decrease transaction costs, increase diversity of actors, reduce overall costs, open new, higher-risk/higher-impact approaches to research, and provide entrepreneurs freedom to operate and freedom to innovate. We argue that it is time to re-open science, not only in its now restricted arena of fundamental research, but throughout clinical translation. Our model and attendant recommendations map onto a strategy to accelerate discovery of novel broad-spectrum anti-viral drugs and clinical trials of those drugs, from first-in-human safety-focused trials to late stage trials for efficacy. The goal is to ensure low-cost and rapid access, globally, and to ensure that Canadians do not pay a premium for drugs developed from Canadian science.