COVID-19: To treat or not to treat? April 14 update

Roman Jaeschke

Dr Roman Jaeschke, professor in the Departments of Medicine and of Health Research Method, Evidence and Impact, physician lead of the Critical Care Response Team at St Joseph’s Healthcare Hamilton, and editor in chief of the McMaster Textbook of Internal Medicine, considers fundamental questions regarding treatment of coronavirus disease 2019 (COVID-19).

Roman Jaeschke, MD, MSc: Good morning. Welcome to another edition of McMaster Perspective. This is slightly unusual, because I’m recording this interview with myself.

Over the last few weeks we have all become experts in coronavirus disease 2019 (COVID-19). It takes an extraordinary amount of time and effort. I’m getting a lot of questions regarding treatments, prevention, treatment of mild cases, treatment of severe cases. I’m interviewing my interlocutors about these issues and I plan to ask a number of people a few questions. I’ve decided to present my own views in this area before I interview them, even though I’m planning to stay neutral.

Those questions will be as follows:

1) Is there any specific treatment for COVID-19 that has reached a threshold where we should suggest its use on a wider scale? My answer as of April 14, 2020, is no.

2) Should we use any of those treatments outside of randomized controlled trials (RCTs)? My opinion is that we should not.

On the other hand, I understand there are people who feel very strongly about using specific medications. Considering emotional, psychological, moral, and cultural circumstances, if a clinician and a patient together decide to take the risk and use medications with no proven efficacy, I do not believe there are moral or ethical rights that should clearly prevent them from doing so. There may be some administrative, legal, or organizational barriers, and certainly access-related barriers. Nevertheless, if there is honesty and exchange of adequate information, then different people make different decisions when presented with the same set of facts.

There is also a notion that not using anything, any specific medication, is unethical these days. While disagreeing with this, I would still say there are options that are being actively pursued. For example, there is a concept that we’ll talk more about later of adaptive trial designs, where people may be simultaneously randomized to a number of interventions, even 4 or 5, including antimalarials, antibiotics, immunomodulators, antivirals, and so forth, of which at least 1 is to be active, and in this case people will get something (ie, will receive at least 1 potential intervention).

I’m planning to pose these questions to a number of people. I will invite people who have different opinions. This is, however, as of this morning, April 14, my own McMaster perspective. Thank you for listening.

See also
  • COVID-19 resource hub Resources helpful in addressing the coronavirus disease 2019 (COVID-19) epidemic.
  • COVID-19 McMaster Survival Guide The COVID-19 McMaster Survival Guide is a concise, comprehensive, and practical manual addressing a broad range of topics related to COVID-19. Updated on an ongoing basis.
  • COVID-19: To treat or not to treat? April 21 update Dr Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University and one of the founders of EBM, discusses the rationale behind making treatment decisions in patients with COVID-19.
  • COVID-19: To treat or not to treat? April 15 update. Part 1 Dr Jean-Louis Vincent, professor of intensive care medicine at Université libre de Bruxelles and past president of the World Federation of Societies of Intensive and Critical Care Medicine, discusses the currently available treatment options for COVID-19.
  • COVID-19: To treat or not to treat? April 14 update Dr Bram Rochwerg, assistant professor in the Division of Critical Care and medical lead in the intensive care unit at the Juravinski Hospital, discusses the currently available treatment options for COVID-19 and their use outside of clinical trials.
  • COVID-19: CPGs for critically ill patients. Part 7: Other therapeutics Dr Waleed Alhazzani, lead author of the newest SSC guidelines, talks us through the evidence behind different treatment options (IVIG, antivirals, antimalarials).
  • COVID-19: CPGs for critically ill patients. Part 6: Steroids Dr Waleed Alhazzani, associate professor in the Division of Critical Care and chair of Surviving Sepsis guidelines, discusses the rationale behind recommendations on steroid therapy in COVID-19 patients with or without ARDS.
  • COVID-19: Expert Q&A Dr Dominik Mertz, associate professor in the Division of Infectious Diseases at McMaster University and medical director of infection prevention and control at Hamilton Health Sciences, describes the current status of the COVID-19 pandemic and answers some of the commonly repeated questions about testing, immunity, and masks.
  • COVID-19: Past lessons and future predictions. March 10 update Dr Mark Loeb, professor in the Department of Pathology and Molecular Medicine and Michael G. DeGroote Chair in Infectious Diseases at McMaster University, reviews the essential terminology for discussing the current COVID-19 situation and draws parallels with flu pandemics.

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