This is a great read on the nuance/trying to make sense of the remdesivir data! I highly respect @PaulSaxMD and his interpretation and clinical experience. This is how I want to feel about it too, but if I am being honest with myself the data do not really support it (1/7).
If time from onset of symptoms was the driver here, the difference seen in <=10 days, shouldn’t go away when we split it at 9 days. In fact, the shortest time to recovery was driven by the group days 10-12 From onset (<=6 days was no better). From supplement of ACTT-1
So those ten day splits are literally driven by patients presenting exactly on day 10 only. I struggle to see that as suggesting time from onset is meaningfully impacting any of the data we have to date.
Finally, I do not think we can claim that the data suggest a mortality benefit in non-ventilated patients, but then write off the same discordance in the direction of harm for ventilated patients as statistical noise. It is more likely that neither are real.
Remember, in solidarity there was also no improvement in progression to the need for ventilatory support in those not on it at baseline. This again suggests against a benefit in non-ventilated patients.
I do agree with the “probably (possibly) a modest benefit in some patients”, but do not think it is in the vicinity of the magnitude of the top line of ACTT-1. The other two trials (Wuhan RCT, Solidarity) suggest no impact on length of stay or progression of illness.
If we believe that there is a target population then I am very supportive of additional trials in that population - but even the most favorable view of the data as a whole suggests that there is not so large of a benefit that we can‘t study it first before using it there.

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More from @jpogue1

31 Jul
It has been pointed out that my thread yesterday omitted observational data, most notably the Henry Ford study. This was done intentionally, because the observational data for (and against) hydroxychloroquine is honestly confounded beyond salvaging. Allow me to explain.
Those who know me are aware I am highly supportive of well performed retrospective observational studies. It is actually the focus of my research career to date and will continue to be moving forward
However, there are challenges that need to be addressed for the data to have meaning. The primary one is something we call confounding by indication; that is there is a clinical reason that a treating physician chooses an agent (or doesn’t) and it is hard to fix that limitation
Read 25 tweets
30 Jul
I promise that if #hydroxychloroquine was an effective therapy for #covid19 we would tell you. Many of us (myself definitely included) were hopeful that it would be at the onset of the pandemic. We now know definitively that it doesn’t work. A (long) thread
The initial hope for HCQ stemmed from in vitro work in Vero (kidney) Cells that showed potent inhibitory activity of CQ (and subsequently HCQ).
Unfortunately, recent data demonstrate that Vero cells are a particularly bad option for assessing the in vitro activity of HCQ against SARS CoV-2 due to HCQs mechanism of action. Allow me to explain
Read 35 tweets
22 Mar
Welcome new followers. I wanted to pause and reflect before further commenting – which is something I would highly recommend we all do. With that, another brief thread
First off, for those asking, I'm an infectious diseases clinical pharmacist.Critically assessing the totality of evidence and working w/ physician colleagues to make patient care decisions is quite literally what we do. We are drug therapy experts and always work to optimize care
Second, I want to be crystal clear that we all want to find a therapeutic solution to #COVID19. Every single one of us. However, we cannot suspend disbelief to get there. We need to be critical of the emerging evidence and prioritize completion of well controlled trials
Read 14 tweets
20 Mar
Guys. We need to talk about this Hydroxychloroquine + Azithromycin thing. It is out of hand. It all stems from this study that came out today. The study design: Comparative viral eradication on day 6 between HCQ, HCQ + Azithro, and control (not treated) COVID-19 patients.
The gist of the excitement is this figure describing viral "eradication" rates between the groups at day 6:
HCQ + Azithro group 6/6 (100%) by day 6
HCQ mono therapy 8/14 (57%)
Control 2/16 (13%)
Sounds amazing right? I mean this kinda stuff gets Dr. Oz all worked up.
But as always. The devil is in the details. Per the methods the study started with 26 pts in the HCQ group and 16 control. Then why only 20 HCQ pts in the analysis? Because in order to be in the cohort you had to be evaluable (swab) at day 6. That meant 6 HCQ pts were ineligible
Read 14 tweets

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