July 15, 2020

Doctors are (slowly) getting better at treating Covid-19. Here's how.

Daily Briefing

    After months of trial by fire, providers are reporting that they've identified ways to reduce death and injury among Covid-19 patients. Here are the treatments many providers rely on—and some that are still up for debate.

    Covid-19 guidance from clinicians at the forefront

    'Trial and error'

    Although the world is several months into the global coronavirus pandemic, there is still no established cure, treatment, or vaccine for the novel coronavirus or Covid-19, the disease the virus causes. Lacking a universal treatment protocol, providers worldwide have had to resort to "trial and error" as they sought to reduce death and injury among Covid-19 patients, Bloomberg reports.

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    But now, data indicates that providers' makeshift treatment methods are saving more Covid-19 patients' lives. Despite continued increases in new coronavirus cases, growth in newly reported deaths linked the virus has declined in many countries. In June, there was an average of 4,599 new deaths linked to the coronavirus each day worldwide, down from an average of 6,375 daily deaths in April, Reuters reports. In the United States, the daily total of newly reported deaths linked to the virus dropped from between 2,000 and 3,000 in April and May to below 1,000 in June—though growth in the country's daily death toll is once again starting to accelerate amid a resurgence in America's coronavirus epidemic.

    Still, according to Reuters, which spoke with 30 physicians from around the world, breakthroughs in research and anecdotal advice from their colleagues has made them feel more prepared to treat patients with Covid-19.

    "We are well-positioned for a second wave," said Gopi Patel, an infectious disease doctor at Mount Sinai Hospital. "We know so much more."

    The treatments

    Evolving protocols

    Providers said hospital protocols often evolve with new knowledge and research surrounding Covid-19, and those changes can help bolster patients' outcomes.

    For example, some hospitals have incorporated a practice known as "proning," or positioning patients on their stomachs to facilitate breathing, into their treatment protocols for Covid-19. Many doctors—including Sanja Jelic, a critical care doctor at Columbia University Irving Medical Center—began using proning to relieve pressure on patients' lungs, and the practice soon became widespread for treating patients with Covid-19, Bloomberg reports.

    Jelic said she started asking patients to roll onto their stomachs while they were waiting to be intubated for ventilation and found the practice seemed to help. "I remember, the first three patients really had a dramatic improvement in their oxygenation," she said.

    Some providers have started using the method in hopes to delay ventilation or prevent patients from needing ventilation altogether, Reuters reports. Research by Jelic and colleagues published last month in JAMA Internal Medicine demonstrated that the practice improved oxygenation and could even reduce the probability that patients would need intubation at all, according to Bloomberg.

    In addition, some hospitals report that changes made early on in the pandemic have prepared providers for handling additional surges of Covid-19 patients.

    Andra Blomkalns, head of emergency medicine at Stanford Health Care, said Covid-19 treatment guidelines changed almost every day during the first few weeks of the pandemic. The hospital started out following CDC guidelines for Covid-19 treatment, and later modified its protocols while facing shortages of certain supplies, including personal protective equipment (PPE). Now, the hospital is operating using additional protocols that are not included in CDC's guidelines, Blomkalns said.

    The original "hysteria … is not there anymore," Blomkalns said. "We have an entire team whose only job is getting PPE."

    Tom Wingfield, a clinical lecturer at the Liverpool School of Tropical Medicine, said, "Our hospital infrastructure, and the way that we ... manage people coming through the door is a lot slicker than it was earlier in the [pandemic]."

    In Brazil, Hospital Israelita Albert Einstein changed its internal protocol for Covid-19 treatment about 50 times since the start of the pandemic to adapt to evolving conditions and evidence, according to Moacyr Silva Júnior, an infectious disease specialist at the hospital. According to Júnior, the hospital consistently changed its protocols regarding administering medication and the use of PPE. "In only three months, a resounding amount of scientific work on Covid-19 has been published," he noted.

    Therapies both new and old

    Hospitals also are enrolling thousands of patients in clinical trials to test potential new therapies for Covid-19, including both novel treatments and new cocktails of older drugs, Reuters reports.

    Many hospitals have reported positive outcomes using convalescent plasma, or blood containing antibodies from recovered Covid-19 patients, to treat new patients with the disease.

    In a trial at Mount Sinai Hospital, for instance, researchers found that patients with severe Covid-19 who were treated with convalescent plasma often needed less oxygen support and more likely to stabilize than Covid-19 patients who didn't receive convalescent plasma.

    John Deledda, CMO at Henry Ford Hospital, said "anecdotally everyone can provide stories" about the success of convalescent plasma as a Covid-19 treatment.

    However, Reuters reports that some researchers have heeded mixed results about the potential treatment, which is still the subject of various clinical trials.

    Research similarly has unveiled mixed results for other potential treatments, including using a combination of the HIV medications ritonavir and lopinavir, according to Bloomberg, with one study showing that the cocktail failed to reduce death in hospitalized Covid-19 patients. But Reuters reports that providers in some countries, including the United Arab Emirates, have reported having some success with treating Covid-19 patients with the drugs.

    Gilead Sciences' antiviral drug remdesivir is the most promising experimental treatment for Covid-19. Research published in May showed that remdesivir was associated with faster recovery times among some Covid-19 patients, and an analysis released by Gilead on Friday showed that Covid-19 patients treated with remdesivir recovered sooner and were 62% less likely to die when compared with data from a historical control group. The new analysis is based on data from a clinical trial that did not include a new control group of patients.

    FDA in May issued an emergency use authorization allowing providers to use remdesivir to treat patients with severe cases of Covid-19, and providers since then have learned a good deal about how to use the medication in such patients.

    For instance, while officials originally recommended using remdesivir only in critically ill patients, providers found that administering the drug before patients' conditions were critical could produce better outcomes.

    "We started finding that … the sooner you get treated with it, the better," Andrew Staricco, CMO at McLaren Health Care, said. He added, "We've revisited our criteria for giving it to patients three different times."

    Overall, research on remdesivir as a Covid-19 treatment remains scarce, but doctors say anecdotal evidence lends strong support for its use.

    Treating respiratory distress

    According to the Wall Street Journal, many doctors appear to be split on the best practice for treating lung injuries caused by the novel coronavirus, resulting in providers and hospitals developing different treatment protocols.

    Some doctors are treating the injuries the same way they would treat acute respiratory distress syndrome (ARDS), which is caused by widespread inflammation in the lungs.

    Jarrod Mosier, a physician and associate professor of emergency medicine and medicine at the University of Arizona, said he believes Covid-19 patients are experiencing ARDS. "To me, that is the thing that will save the most lives in this disease—just excellent critical care management of ARDS," he said.

    As a result, he believes using a ventilator to apply positive pressure to patients' lungs is critical, but he added that too much air pressure could cause more damage. "I look at all of those things and tinker with the ventilator for a good while every day to try to find that balance," he said.

    But other doctors think Covid-19 patients aren't experiencing classic ARDS. Instead, these doctors say patients are experiencing damage that makes their lungs more elastic, which typically isn't associated with ARDS. Although these patients have low blood-oxygen levels, doctors worry that using ventilators as they're typically used for ARDS patients could redirect blood flow away from certain parts of the lungs—and make the damage worse. As such, doctors have been treating such patients with lower levels of positive pressure and a higher volume of air per breath than is commonly used for treating ARDS patients, the Journal reports.

    Information sharing

    Overall, providers largely have said that increased information sharing between clinicians has helped prepare them to treat Covid-19 patients.

    Staricco, for instance, said McLaren Health adapted its policy on treating Covid-19 patients with blood thinners using information shared from Detroit Medical Center and Vanderbilt University Medical Center. There was "lots of copy-catting going on," Staricco said.

    To help facilitate information sharing, the World Health Organization (WHO) is collecting data from hospitals treating Covid-19 patients in multiple countries. Sylvie Briand, WHO's director for global infectious hazard preparedness, said the organization aims to develop a "tool box" to help providers reduce mortality among patients with Covid-19 (Brown, Reuters, 6/26; Gale, Bloomberg, 7/6; Toy/Maremont, Wall Street Journal, 7/1).

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