Day 1 of the RCP annual conference included a plenary session focusing on what we have learnt from COVID-19 research. The presentations were by Martin Landray, professor of epidemiology at the University of Oxford, on lessons learnt from the RECOVERY trial, and Anthony Gordon, professor of anaesthesia and critical care, Imperial College London, on REMAP-CAP.
Professor Martin Landray gave a whistlestop tour of the design, implementation and initial results of the RECOVERY trial for COVID-19 treatments. He emphasised the importance of large-scale, randomised clinical trials in providing compelling evidence that changes practice, such as the finding that dexamethasone reduces mortality for patients requiring oxygen or ventilation. His key points were that trials must be inclusive for both patients and staff with minimal extra work (especially important under the pressures of the COVID-19 pandemic) and focused on outcomes that matter, and the value of communication and transparency from design to results.
RECOVERY has been a UK-wide trial, although some hospitals have recruited a much bigger proportion of patients with COVID-19 than others. Professor Landray stated that COVID-19 has demonstrated the need to bring clinical trials back to the bedside – they provide the opportunity for more junior doctors to participate in research, and give patients access to treatments they would otherwise not have had.
Next, Professor Anthony Gordon spoke about what we have learnt about COVID-19 from the REMAP-CAP trial. His starter for ten was that research in a pandemic is vital – difficult, but it can be done. REMAP-CAP was set up before COVID-19, initially with EU funding, as part of pandemic preparedness planning; it is an international, adaptive platform trial for severely ill patients with community-acquired pneumonia that could be adapted to a pandemic infection. This has been done for COVID-19, and with additional funding from the National Institute for Health Research, REMAP-CAP has been expanded into a much larger trial with over 2,500 participants in the UK.
After giving an overview of the REMAP-CAP set-up, Professor Gordon described the trial’s significant results so far. It has demonstrated that either dexamethasone or hydrocortisone can be used to treat patients requiring oxygen or ventilation (particuarly important in drug shortages): dexamethasone’s effect is not drug specific, but a class effect for corticosteroids. REMAP-CAP has also demonstrated futility for lopinavir–ritonavir and for therapeutic anticoagulation (heparin) in ICU patients unless there is a proven indication. Excitingly, recent results demonstrate a positive effect for tocilizumab compared with control.
Both the RECOVERY and REMAP-CAP trials have given us a vital evidence base for treaments that will give COVID-19 patients the best chance of survival. After their plenary presentations, Professors Landray and Gordon answered questions in a live Q&A session chaired by Dr Louise Wood CBE, director of science and evidence department, Department of Health and Social Care. Questions included the rationale for trialling colchicine and whether there is a plan to include ivermectin in the RECOVERY trial, what trials show to be the best antiviral for treating COVID-19, and whether there is a role for steroid treatment for COVID-19 patients in the community.
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