The biggest missed COVID opportunity

It’s kind of astounding to think about how much COVID news has happened since the beginning of the pandemic.

2 million infected Americans. 117,000 dead Americans. A closed economy. A stock market crash. 40 million unemployed. A stock market rebound. National protests. An opening economy. Hints of a second wave.

It’s also the greatest missed scientific opportunity I can think of. If you search Pubmed for COVID-19, you get a result of over 22,000 articles. The sheer volume of published COVID research is insane.

The more insane part is how low quality all of it is. I’ve written in this newsletter about a lot of the mediocre studies that have been hyped as game-changing news. To date, here’s what we have actually learned about how to treat COVID:

• Remdesivir seems to have a positive impact on disease duration

• Hydroxychloroquine doesn’t seem to do much for treatment or prevention

• Lopinavir-ritonavir (Kaletra) is probably ineffective

• Dexamethasone is newly reported to be effective in severe illness (I’m not ready to become irrationally exhuberant after all of the data retractions and misleading reports when all we have is a press release on the top line results)

That’s pretty much it.

22,000 papers written and that’s all we know about treatment

We don’t know how we should be preventing blood clots.

We don’t know how well - or if - convalescent plasma works.

We don’t know how we should treat the cytokine storm. [Well, maybe we should use dexamethasone based on the RECOVERY data, but I’ve written before about my misgivings with science by press release.]

We don’t know if we should use biologic agents like IL-6 inhibitors.

It’s really incredible that we still have this massive knowledge gap despite all of this medical literature. Of course, I’m being a bit overly dramatic to say that we haven’t learned anything.

We learned that masks are really important tools to reduce viral spread and that lots of people were wrong about this.

We learned that ACE inhibitors and angiotensin receptor blockers don’t increase your COVID risk.

We learned that proning patients (AKA adult tummy time) can improve oxygenation when oxygen levels are low and may help avoid intubation.

But the geometric proliferation of medical literature with a concomitant dearth of randomized controlled trials means that our knowledge about how to treat critically ill COVID-19 patients is much less than it should be.

This is an epic policy failure and a gigantic missed opportunity

From the beginning of this pandemic, there should have been a focused effort across US medical centers to perform randomized, placebo controlled trials for all of the treatments that we have been considering.

With the huge numbers of COVID patients we’ve been seeing, even enrolling 10% of hospitalized patients in randomized controlled trials would give unbelievable insight into how to treat this disease.

But we haven’t done this.

I don’t mean to suggest that researchers aren’t working overtime to learn about this disease. They are. But there has been no concerted effort from US policymakers to make sure that we are answering important clinical questions.

Instead, we get emergency use authorizations and endless media reports about what may or may not work.

Why aren’t we doing this like the NHS?

The NHS has put together the RECOVERY trial consortium, a coordinated UK research effort that’s been put together to answer a lot of important questions on what treatments work in COVID.

From the RECOVERY website:

A range of potential treatments have been suggested for COVID-19 but nobody knows if any of them will turn out to be more effective in helping people recover than the usual standard of hospital care which all patients will receive. The RECOVERY Trial will begin by testing some of these suggested treatments: 

• Lopinavir-Ritonavir (commonly used to treat HIV)

• Low-dose Dexamethasone - RECRUITMENT CLOSED TO ADULTS

• Hydroxychloroquine - RECRUITMENT CLOSED

• Azithromycin (a commonly used antibiotic)

• Tocilizumab (an anti-inflammatory treatment given by injection)

• Convalescent plasma (collected from donors who have recovered from COVID-19 and contains antibodies against the SARS-CoV-2 virus).

It’s really disappointing that we haven’t had a coordinated national effort here to figure out what works and what doesn’t work for COVID.

A letter to doctors across the UK signed by the Chief Medical Officers of England, Scotland, Wales, and Northern Ireland, and the National Director of the NHS says, “We are writing to ask that every effort is made to enroll COVID-19 patients in the national priority clinical trials; there are trials in primary care, hospital settings and ICUs.”

The story of our national research here is the same as the story of our national testing - all tactics, no strategy. It’s a gigantic missed opportunity and a real policy failure that has been under discussed in the popular press.