Commentary: COVID-19 treatment researchers should be cooperating not trash-talking each other

OXFORD: Rivals Usain Bolt and Justin Gatlin trash-talked each other before the 2016 Olympics, with Bolt calling Gatlin “old man”, and Gatlin calling Bolt “middle aged”.

The banter was entertaining but vanished into insignificance when Bolt won. After the race, both athletes shook hands and accepted the result.

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Something like trash-talking is happening in the race for a treatment for COVID-19, but – unlike with Bolt and Gatlins race, which decided the matter – there is no fair test of the two top contending treatments being conducted.

The two competing treatments getting the most press are chloroquine, or its cousin hydroxychloroquine (usually given with an antibiotic), and remdesivir. Like almost all medical treatments, they both have benefits and harms.

READ: Nearly a dozen approved drugs could be effective against COVID-19: Study

READ: Ebola drug remdesivir used to treat COVID-19 patients in Singapore as part of clinical trials

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Hydroxychloroquine is promoted by world-renowned French virologist Didier Raoult, who looks like a rock star. Remdesivir is being endorsed by Donald Trumps scientific adviser, Anthony Fauci.

Fauci claimed that Raoults treatment may have “no effect”, and Raoult returned the favour by accusing Faucis trial of “surprisingly” changing outcomes mid-stream (death rate was initially the primary outcome measure but this was replaced with the time it took patients to recover).

Missing from this exchange is a call for a fair head-to-head test of the two treatments.

RAOULTS HYDROXYCHLOROQUINE STUDY

Hydroxychloroquine is a cheap treatment for malaria, which some test-tube studies suggest inhibits the growth of viruses such as the novel coronavirus.

FILE PHOTO: A nurse shows a Hydroxychloroquine pill, amid the coronavirus disease (COVID-19) outbreak, at Nossa Senhora da Conceicao hospital in Porto Alegre, Brazil, April 23, 2020. REUTERS/Diego Vara

Raoult noticed that it appeared to be very effective in most of his COVID-19 patients. He conducted a few trials that seemed to show a large effect, but the trials were small (fewer than 80 patients) and it seemed to have serious side-effects in some patients.

Raoult claims that patients in his hospital wouldnt have agreed to a “fair test” of his treatment against any other (or a placebo) because they wanted hydroxychloroquine. This may be true in his hometown of Marseilles, where he has celebrity status, but not elsewhere.

Also, the fact that he has fans in Marseilles should not have stopped him from publishing a protocol for a comparative trial.

Without a fair test, fans of remdesivir (and critics of hydroxychloroquine) will continue to find flaws with Raoults study.

READ: Commentary: Can chloroquine really treat COVID-19?

READ: Ebola drug remdesivir used to treat COVID-19 patients in Singapore as part of clinical trials

FAUCIS REMDESIVIR TRIAL

Remdesivir, a drug developed by Gilead Sciences, has been shown to work in monkeys, but it flopped in the first trial for treating humans with COVID-19.

Revealing the dangerously non-transparent nature of the science in this area, the World Health Organization (WHO) initially posted the results of the failed trial and subsequently took the data down. Simultaneously, Gilead Sciences accused the WHO of “misrepresenting” the trial.

Another trial that didnt test the drug against a control group, reported by industry-funded authors, found that 36 of the 53 patients who took remdesivir had improved lung function.

Yet 60 per cent of the patients had at least one side-effect, including abnormal liver function.

FILE PHOTO: Vials of investigational coronavirus disease (COVID-19) treatment drug remdesivir are capped at a Gilead Sciences facility in La Verne, California, U.S. March 18, 2020. Gilead Sciences Inc/Handout via REUTERS/File Photo

Most recently, the US National Institutes of Health funded a trial comparing remdesivir with placebos in 1,000 patients. The drug seemed to reduce the length of stay in hospital from 14 days – which was how long those who took a placebo were in hospital – to 11 days.

However, Fauci announced the results on national television before the study was reviewed, so nobody can confirm independently whether it was a fair test.

A problem with Faucis trial is that the protocol was changed after the trial started. Initially, they were supposed to measure death, which is barely susceptible to bias. They changed this to length of stay in hospital, which is more susceptible to bias.

Changing the protocol mid-stream is sometimes justified, but no rationale was provided.

Even if the trial of remdesivir versus placebo had no flaws, believers in hydroxychloroquine could say that their treatment would have fared better if it had been compared directly.

READ: US to allow states to distribute Gilead's remdesivir to fight COVID-19

READ: Commentary: COVID-19 vaccine – why is it taking so long to develop one?

A FAIR SIDE-BY SIDE TRIAL

There is plenty more to the story of hydroxychloroquine and remdesivir. Last time I checked, there were almost 100 trials of either hydroxychloroquine or remdesivir registered worldwide.

The problem is that none of them amounts to a fair side-by-side trial. A fair comparative test of a treatment is (conceptually) no more complex than a 100m race. Such comparative tests are the heart of evidence-based medicine.

In brief, we need a randomised, double-blind trial that compares one treatment against another. Such a trial uses (something like) flipping a coin to decide who gets what.

Otherwise, if people choose which treatment they are on, it could turn out that, say, younger, healthier people chose one treatment over another. That would be like giving one of the treatments a head start.

(Photo: AFP/Alberto PIZZOLI)Read More – Source