Public Health Watch: Tracing the Evolution of COVID-19 Treatment in Hospitalized Patients

Annals of Internal Medicine study shows move away from hydroxychloroquine to more proven therapies.

The treatment for any disease constantly evolves—particularly when the disease in question is caused by an emerging pathogen.

Unfortunately, skeptics continue to use the changing science around the treatment (as well as the prevention and spread) of COVID-19 as evidence that it is somehow not up to snuff. Nothing could be further from the truth, in most cases, at least when it comes to caring for patients with severe disease.

On that score, although there is still no cure for the disease caused by SARS-CoV-2, there are treatments that do provide some relief.

In a study published on August 17 by Annals of Internal Medicine, researchers from across the country have attempted to chronicle the narrative arc—for lack of a better phrase—of COVID-19 care. The Cliffs Notes version (forgive the data reference): The story starts with hydroxychloroquine, continues through remdesivir, and ends (at least for now) with dexamethasone and some cautious optimism.

“Earlier in the pandemic, patients and clinicians were desperately looking for COVID-19 treatment,” Hemalkumar B. Mehta, PhD, an assistant professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore, told Contagion. “Unfortunately, the use of hydroxychloroquine was based on weak scientific evidence [and] media coverage and hype increased public interest in hydroxychloroquine. As soon as the scientific evidence showed no benefits and possible harms of hydroxychloroquine, clinicians stopped using it. The case of hydroxychloroquine provides a good reminder that solid scientific evidence should be a major driver for COVID-19 treatment.”

Over the course of the study period, February 1, 2020 through February 28, 2021, among 137,870 people hospitalized with confirmed or suspected COVID-19, 8754 (6.3%) received hydroxychloroquine. However, use of the drug increased during March 2020, peaking at 42%, and started to drop by April 2020, as new data emerged demonstrating that it offered little, if any clinical benefit. By February of this year, just 0.6% of hospitalized COVID-19 patients were given the drug.

Conversely, 29,272 (21.2%) of the study patients were given remdesivir and 53,909 (39.1%) were administered dexamethasone over the 13-month study period, gradually increasing throughout. Indeed, following release of results from the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial in mid-June, 78% to 84% of patients on invasive mechanical ventilation received dexamethasone or another glucocorticoid, the researchers found. Remdesivir use peaked at 27% in February.

However, even this increased use might not have been sufficient. Of the patients who may have benefited from dexamethasone, for example, approximately 1 in 5 patients did not receive the steroid, according to Dr. Mehta. Its use peaked at 53% of potentially eligible patients in November 2020 and stood at 33% in February, but these figures vary “substantially” across health centers (intraclass correlation coefficient, 14.2%).

“We found that remdesivir and dexamethasone were used variably across health systems [and] we need to ensure that these drugs are given to the right patients and used consistently… to improve outcomes among patients hospitalized with COVID-19,” Mehta said. For example, “there is compelling evidence that dexamethasone is beneficial to those with COVID who are hospitalized and require supplemental oxygen. Because the pandemic is still ongoing, we must continue to generate scientific evidence on COVID-19 treatment to help patients and clinicians select appropriate drug therapies.”