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Pessoa-Amorim G, Campbell M, Fletcher L, Horby P, Landray M, Mafham M, Haynes R. Making trials part of good clinical care: lessons from the RECOVERY trial. Future Healthc J 2021; 8:e243-e250. [PMID: 34286192 PMCID: PMC8285150 DOI: 10.7861/fhj.2021-0083] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
When COVID-19 hit the UK in early 2020, there were no known treatments for a condition that results in the death of around one in four patients hospitalised with this disease. Around the world, possible treatments were administered to huge numbers of patients, without any reliable assessments of safety and efficacy. The rapid generation of high-quality evidence was vital. RECOVERY is a streamlined, pragmatic, randomised controlled trial, which was set up in response to this challenge. As of April 2021, over 39,000 patients have been enrolled from 178 hospital sites in the UK. Within 100 days of its initiation, RECOVERY demonstrated that dexamethasone improves survival for patients with severe disease; a result that was rapidly implemented in the UK and internationally saving hundreds of thousands of lives. Importantly, it also showed that other widely used treatments (such as hydroxychloroquine and azithromycin) have no meaningful benefit for hospitalised patients. This was only possible through randomisation of large numbers of patients and the adoption of streamlined and pragmatic procedures focused on quality, together with widespread collaboration focused on a single goal. RECOVERY illustrates how clinical trials and healthcare can be integrated, even in a pandemic. This approach provides new opportunities to generate the evidence needed for high-quality healthcare not only for a pandemic but for the many other conditions that place a burden on patients and the healthcare system.
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Affiliation(s)
- Guilherme Pessoa-Amorim
- Nuffield Department of Population Health, Oxford, UK and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- joint first authors
| | - Mark Campbell
- Nuffield Department of Population Health, Oxford, UK and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- joint first authors
| | - Lucy Fletcher
- Nuffield Department of Population Health, Oxford, UK
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Martin Landray
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, NIHR Oxford Biomedical Research Centre, Oxford, UK and Health Data Research UK, Oxford, UK
| | - Marion Mafham
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK and Health Data Research UK, Oxford, UK
| | - Richard Haynes
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Singh V, Garg S, Klimek M, Sinha RR, Dhanwal D. COVID-19 and Clinical Trials: Current Challenges and Future Directions. Rev Recent Clin Trials 2021; 16:258-261. [PMID: 33480349 DOI: 10.2174/1574887116666210122160705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The outbreak of coronavirus disease (COVID-19) has posed a major threat to people's lives across the globe. It has drastically changed the way we perceive this world. A paradigm shift was observed globally as the world's emphasis shifted to testing, diagnosis, treatment, and developing a coronavirus cure. Clinical trials were also not untouched by this. The coronavirus pandemic has abhorrently affected the day-to-day clinical trial activities at sites. METHODS The status of various ongoing clinical trials was assessed through a literature search, which also includes clinical trial portals. Our evaluations were based on these observations. RESULTS Multiple challenges were present in clinical trials as recruitment, retention, the safety of trial subjects, protocol compliance, and this made the world to re-think to incorporate newer strategies and to cope with this untoward situation. CONCLUSION Digitalization of clinical trials as virtual management of adverse events, remote monitoring visits, and web-based consulting with trial subjects are potential directions that can be applied to better manage clinical trials worldwide.
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Affiliation(s)
- Vinay Singh
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Sandeep Garg
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Monika Klimek
- Department of Laboratory Diagnostics, Medical University of Lublin, Lublin, Poland
| | - Rajeev Ranjan Sinha
- Department of Pharmacology, Lord Buddha Koshi Medical College and Hospitals, Saharsa, Bihar, India
| | - Dinesh Dhanwal
- Department of Endocrinology, NMC Speciality Hospitals, Abu Dhabi, United Arab Emirates
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Ford N, Vitoria M, Rangaraj A, Norris SL, Calmy A, Doherty M. Systematic review of the efficacy and safety of antiretroviral drugs against SARS, MERS or COVID-19: initial assessment. J Int AIDS Soc 2020; 23:e25489. [PMID: 32293807 PMCID: PMC7158851 DOI: 10.1002/jia2.25489] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Several antiretroviral drugs are being considered for the treatment of COVID-19, the disease caused by a newly identified coronavirus, (SARS-CoV-2). We systematically reviewed the clinical outcomes of using antiretroviral drugs for the prevention and treatment of coronaviruses and planned clinical trials. METHODS Three databases were screened from inception to 30 March 2020 for studies reporting clinical outcomes of patients with SARS, MERS or COVID-19 treated with antiretrovirals. RESULTS From an initial screen of 433 titles, two randomized trials and 24 observational studies provided clinical outcome data on the use of antiretroviral drugs; most studies reported outcomes using LPV/r as treatment. Of the 21 observational studies reporting treatment outcomes, there were three studies among patients with SARS, six studies among patients with MERS and 12 studies among patients with COVID-19. In one randomized trial 99 patients with severe COVID-19 illness were randomized to receive LPV/r (400/100 mg twice a day) and 100 patients to standard of care for 14 days: LPV/r was not associated with a statistically significant difference in time to clinical improvement, although LPV/r given within 12 days of symptoms was associated with shorter time to clinical improvement; 28 day mortality was numerically lower in the LPV/r group (14/99) compared to the control group (25/100), but this difference was not statistically significant. The second trial found no benefit. The certainty of the evidence for the randomized trials was low. In the observational studies 3 out of 361 patients who received LPV/r died; the certainty of evidence was very low. Three studies reported a possible protective effect of LPV/r as post-exposure prophylaxis. Again, the certainty of the evidence was very low due to uncertainty due to limited sample size. CONCLUSIONS On the basis of the available evidence it is uncertain whether LPV/r and other antiretrovirals improve clinical outcomes or prevent infection among patients at high risk of acquiring COVID-19.
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Affiliation(s)
- Nathan Ford
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Marco Vitoria
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Ajay Rangaraj
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Susan L Norris
- Science DivisionQuality of Norms and Standards DepartmentWorld Health OrganizationGenevaSwitzerland
| | - Alexandra Calmy
- HIV/AIDS UnitDivision of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Meg Doherty
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
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Edwards SJL. Ethics of clinical science in a public health emergency: drug discovery at the bedside. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:3-14. [PMID: 23952822 PMCID: PMC4151792 DOI: 10.1080/15265161.2013.813597] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Clinical research under the usual regulatory constraints may be difficult or even impossible in a public health emergency. Regulators must seek to strike a good balance in granting as wide therapeutic access to new drugs as possible at the same time as gathering sound evidence of safety and effectiveness. To inform current policy, I reexamine the philosophical rationale for restricting new medicines to clinical trials, at any stage and for any population of patients (which resides in the precautionary principle), to show that its objective to protect public health, now or in the future, could soon be defeated in a pandemic. Providing wider therapeutic access and coordinating observations and natural experiments, including service delivery by cluster (wedged cluster trials), may provide such a balance. However, there are important questions of fairness to resolve before any such research can proceed.
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Tansey CM, Herridge MS, Heslegrave RJ, Lavery JV. A framework for research ethics review during public emergencies. CMAJ 2010; 182:1533-7. [PMID: 20530166 DOI: 10.1503/cmaj.090976] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Lau EH, Cowling BJ, Muller MP, Ho LM, Tsang T, Lo SV, Louie M, Leung GM. Effectiveness of ribavirin and corticosteroids for severe acute respiratory syndrome. Am J Med 2009; 122:1150.e11-21. [PMID: 19958895 PMCID: PMC7093860 DOI: 10.1016/j.amjmed.2009.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 07/23/2009] [Accepted: 07/24/2009] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Ribavirin and corticosteroids were used widely as front-line treatments for severe acute respiratory syndrome; however, previous evaluations were inconclusive. We assessed the effectiveness of ribavirin and corticosteroids as the initial treatment for severe acute respiratory syndrome using propensity score analysis. METHODS We analyzed data on 1755 patients in Hong Kong and 191 patients in Toronto with severe acute respiratory syndrome using a generalized propensity score approach. RESULTS The adjusted excess case fatality ratios of patients with severe acute respiratory syndrome receiving the combined therapy of ribavirin and corticosteroids within 2 days of admission, compared with those receiving neither treatment within 2 days of admission, were 3.8% (95% confidence interval, -1.5 to 9.2) in Hong Kong and 2.1% (95% confidence interval, -44.3 to 48.5) in Toronto. CONCLUSIONS Our results add strength to the hypothesis that the combination of ribavirin and corticosteroids has no therapeutic benefit when given early during severe acute respiratory syndrome infection. Further studies may investigate the effects of these treatments later in disease course.
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Affiliation(s)
- Eric H.Y. Lau
- School of Public Health, The University of Hong Kong, Hong Kong
| | | | - Matthew P. Muller
- St Michael's Hospital, Toronto, Ontario, Canada
- Canadian Severe Acute Respiratory Syndrome Research Network, Toronto, Ontario, Canada
| | - Lai-Ming Ho
- School of Public Health, The University of Hong Kong, Hong Kong
| | - Thomas Tsang
- Center for Health Protection, Department of Health, Hong Kong
| | | | - Marie Louie
- Canadian Severe Acute Respiratory Syndrome Research Network, Toronto, Ontario, Canada
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Abstract
BACKGROUND TO THE DEBATE In a 2007 article in PLoS Medicine[10], Holger J. Schünemann and colleagues described a new process used by the World Health Organization for rapidly developing clinical management guidelines in emergency situations. These situations include outbreaks of emerging infectious diseases. The authors discussed how they developed such a "rapid advice" guideline for the pharmacological management of avian influenza A (H5N1) virus infection. The guideline recommends giving the antiviral drug oseltamivir at a dose of 75 mg twice daily for five days. In this Debate, Nicholas White argues that such dosing is inadequate, Robert Webster and Elena Govorkova say that combination antiviral therapy should be used, and Tim Uyeki reminds us that clinical care of patients with H5N1 entails much more than antiviral treatment. These issues may also apply to therapy of patients hospitalized with severe disease due to novel swine-origin influenza A (H1N1) virus infection.
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Affiliation(s)
| | - Robert G. Webster
- Department of Infectious Diseases, Division of Virology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
| | - Elena A. Govorkova
- Department of Infectious Diseases, Division of Virology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
| | - Timothy M. Uyeki
- Epidemiology and Prevention Branch, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Abstract
New vaccine technologies and antiviral drugs are needed to prepare for the next influenza pandemic. The threat of a human influenza pandemic has greatly increased over the past several years with the emergence of highly virulent avian influenza viruses, notably H5N1 viruses, which have infected humans in several Asian and European countries. Previous influenza pandemics have arrived with little or no warning, but the current widespread circulation of H5N1 viruses among avian populations and their potential for increased transmission to humans and other mammalian species may afford us an unprecedented opportunity to prepare for the next pandemic threat. The US Department of Health and Human Services is coordinating a national strategy to respond to an influenza pandemic that involves multiple agencies, including the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health (NIH). Within NIH, the National Institute of Allergy and Infectious Diseases (NIAID) conducts basic and clinical research to develop new vaccine technologies and antiviral drugs against influenza viruses. We describe recent research progress in preparing for pandemic influenza.
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Affiliation(s)
- Anthony S Fauci
- National Institutes of Health, Bethesda, Maryland 20892-2520, USA.
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Rubinson L, O'Toole T. Critical care during epidemics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:311-3. [PMID: 16137366 PMCID: PMC1269436 DOI: 10.1186/cc3533] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We recommend several actions that could improve hospitals' abilities to deliver critical care during epidemics involving large numbers of victims. In the absence of careful pre-event planning, demand for critical care services may quickly exceed available intensive care unit (ICU) staff, beds and equipment, leaving the bulk of the infected populace without benefit of potentially lifesaving critical care. The toll of death may be inversely proportional to the ability to augment critical care capacity, so critical care health care professionals must take the lead for planning and preparing to care for numbers of seriously ill patients that far exceed available ICU beds.
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Affiliation(s)
- Lewis Rubinson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
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Cinatl J, Michaelis M, Hoever G, Preiser W, Doerr HW. Development of antiviral therapy for severe acute respiratory syndrome. Antiviral Res 2005; 66:81-97. [PMID: 15878786 PMCID: PMC7132397 DOI: 10.1016/j.antiviral.2005.03.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 03/16/2005] [Accepted: 03/17/2005] [Indexed: 02/09/2023]
Abstract
A new disease, the severe acute respiratory distress syndrome (SARS), caused by the SARS coronavirus (SARS-CoV), emerged at the beginning of 2003 and rapidly spread throughout the world. Although the disease had disappeared in June 2003 its re-emergence cannot be excluded. The development of vaccines against SARS-CoV may take years. Therefore, the availability of effective antiviral drugs against SARS-CoV may be crucial for the control of future SARS outbreaks. In this review, experimental and clinical data about potential anti-SARS drugs is summarised and discussed. Animal model studies will be needed to help to determine which interventions warrant controlled clinical testing.
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Affiliation(s)
- Jindrich Cinatl
- Institut für Medizinische Virologie, Klinikum der Johann Wolfgang Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany.
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Groneberg DA, Poutanen SM, Low DE, Lode H, Welte T, Zabel P. Treatment and vaccines for severe acute respiratory syndrome. THE LANCET. INFECTIOUS DISEASES 2005; 5:147-55. [PMID: 15766649 PMCID: PMC7106466 DOI: 10.1016/s1473-3099(05)01307-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The causative agent of severe acute respiratory syndrome (SARS), which affected over 8000 individuals worldwide and was responsible for over 700 deaths in the 2002-2003 outbreak, is a coronavirus that was unknown before the outbreak. Although many different treatments were used during the outbreak, none were implemented in a controlled fashion. Thus, the optimal treatment for SARS is unknown. Since the outbreak, much work has been done testing new agents against SARS using in-vitro methods and animal models. In addition, global research efforts have focused on the development of vaccines against SARS. Efforts should be made to evaluate the most promising treatments and vaccines in controlled clinical trials, should another SARS outbreak occur.
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Affiliation(s)
- David A Groneberg
- Department of Pneumology, Hannover Medical School, Hannover, Germany.
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Tang J, Chan R. Severe acute respiratory syndrome (SARS) in intensive care units (ICUs): limiting the risk to healthcare workers. CURRENT ANAESTHESIA AND CRITICAL CARE 2004; 15:143-155. [PMID: 32288321 PMCID: PMC7135788 DOI: 10.1016/j.cacc.2004.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The global epidemic of severe acute respiratory syndrome (SARS) during the first half of 2003 resulted in over 8000 cases with more than 800 deaths. Many of those who eventually died, did so in the critical (intensive) care units of various hospitals around the world, and many secondary cases of SARS arose in healthcare workers looking after such patients in these units. Research on SARS coronavirus (SARS CoV) demonstrated that this virus belongs to the same family of viruses, the Coronaviridae that causes the common cold, with some important differences. Properties of this virus have been discovered which can be used to develop important infection control policies within hospitals to limit the number of secondary cases. These properties include environmental survival, transmissibility, viral load in various organs and fluids and periods of symptomatic illness during which infectivity is greatest. Various barrier methods were used throughout the epidemic to protect healthcare workers from SARS, with varying degrees of success. Treatment of SARS patients has mainly involved steroid therapy, with or without ribavirin, but there is no consensus on the best treatment protocol, as yet. This review focuses on the implications of SARS for healthcare workers and patients on critical care units.
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Affiliation(s)
- J.W. Tang
- Royal Free and University College Medical Schools, Centre for Virology, Division of Infection and Immunity, Windeyer Building, 46 Cleveland Street, London W1T 4JF, UK
| | - R.C.W. Chan
- Department of Microbiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Special Administration Region (SAR), China
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