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19 Nov, 8 tweets, 4 min read
Some interesting news here from @remap_cap that #Tocilizumab may improve patient outcomes for COVID-19. Understandable that the team are eager to announce this but given the limited detail and small sample of 303 patients, a few notes of caution are needed.... 1/7
The researchers have declared #Tocilizumab has 'efficacy' for a combination of patient outcomes which include survival and how long patients spend on organ support eg a ventilator. Efficacy means the drug can work in specific (usually well controlled) circumstances. 2/7
It looks like there is a big treatment effect (odds ratio: 1.87) in this trial. That's great but results like this are sometimes too good to be true. Treatment benefits are generally smaller in large trials which account for the real-world problems of delivering patient care. 3/7
This doesn't mean #Tocilizumab won't help, just that the benefit may be weaker than these numbers suggest. The announcement here is for a 'composite' of several patient outcomes bundled together. We may find that individual patient outcomes (eg survival) change much less. 4/7
Important to note that the team have data on lots more patients which they are still analysing. We must wait for this analysis, and interpret the full report of all their findings before we change patient care. 5/7
We must also look at the evidence from all the trials TOGETHER and not just act on results of individual trials we like. The largest trial is likely to be the RECOVERY trial which has been recruiting COVID-19 patients to a #Tocilizumab arm for some time. 6/7
In the interests of full disclosure, I have posted my earlier prediction here. I would be very happy to be proved wrong if it means we have another tool to save lives from this awful disease. But caution is still needed for now. 7/7
....this from @BBCNews. Exactly why I posted the thread. Over optimistic media reports with quotes from doctors like 'amazing result'. False hopes don't help. Only genuine therapies can do that.

Tocilizumab: Arthritis drug may treat severe Covid
bbc.co.uk/news/health-55…

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More from @rupert_pearse

Rupert Pearse Profile picture
21 Nov
An update from ground level across the UK NHS. Things are very different to March. UK COVID-19 projections continue to look more like a ‘slow burn’ than a second wave. But the NHS is under very definite and increasing strain. We are going to have a long hard winter…… 1/12 Photo from @jometsonscott
COVID-19 hospital admissions continue to rise. Now 1750 new patients/day. Much less than the mid-April peak of 3100/day but we will reach that same rate in 8 weeks unless the rise slows. It takes at least four weeks for the lockdown to take effect. Perhaps it will soon? 2/12 https://coronavirus.data.go...
The same pattern is reflected in @ICNARC (independent) data describing COVID-19 admissions to intensive care units: 140 new patients/day and rising with >1500 COVID patients currently in ICU… 3/12 https://www.icnarc.org/Our-...
Read 12 tweets
Rupert Pearse Profile picture
8 Nov
As the NHS enters what will likely be our hardest ever winter, what about the Nightingales….? is a common question, and for some a retort to news that hospitals are struggling to deliver routine patient care in the face of a rapidly rising patient admissions for COVID-19. 1/10
The speed with which the Nightingale Hospitals were established, and our need to believe in them, has left us with the impression that building a major NHS hospital within a few weeks is a thing we can easily do. It isn’t. 2/10
The old Nightingale style wards had rows of beds down each wall. A few nurses could have sight of many patients, and easily communicate with each other. If a patient has a problem (e.g. cardiac arrest) it is easy to spot and help arrives faster. Photo: Wellcome Collection. 3/10
Read 10 tweets
Rupert Pearse Profile picture
1 Nov
As we come to terms with a second lockdown, some reflections on the latest report on Intensive Care admissions for COVID-19 published on Friday. A big shout out to the @ICNARC team and the many ICU staff who collect the data. 1/12
icnarc.org/Our-Audit/Audi…
Patient admissions to Intensive Care with COVID-19 continue to rise steadily. The trajectory is slower than March but still enough to take us to those patient numbers by January. If we don’t stop this rise, even widespread use of temporary ICU facilities will not be enough. 2/12
As expected, ICU admissions currently reflect the heavy impact of COVID-19 on the north of England. Some ICUs are already in trouble. Thoughts with friends and colleagues doing their very best in tough circumstances. 3/12
Read 12 tweets
Rupert Pearse Profile picture
31 Oct
Routine NHS services under big pressure as COVID hospital admissions rise. We cancelled most surgery in the first wave including many cancer operations. Public, patient groups & doctors arguing strongly to keep surgery going this time. This will be a major issue within days. 1/15
Throughout the NHS, we are desperately trying to avoid another major shut down of services. If you are ill, it is important that you contact your GP or come to hospital just as you normally would. We are busy but happy to see you. 2/15
Sadly, there will be many extra deaths during the pandemic from causes other than COVID-19. Hospitals almost completely shut down in Spring for all but the most urgent cases. Many patients stayed at home when ill, either not wanting to burden the NHS or afraid to come in. 3/15
Read 15 tweets
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25 Oct
The suggestion NHS intensive care units thoughtlessly turned away COVID patients purely because of their age is very upsetting. This article quotes ICU doctors off the record but I don't recognise these experiences. We cared for a number of patients aged 80+ on @teamaccu 1/7
A 'triage tool' was developed by @NICEComms but doctors decided not to use it. Instead we fell back on a long standing practice of discussion between experienced NHS consultants (at least three). Patient and family views were always included if possible. 2/7
Being on a ventilator in intensive care is not nice. You wouldn't do it to anyone you loved unless you thought it could help them. But few people outside ICU (doctors or public) realise this and often argue strongly to ventilate patients who have little chance of survival. 3/7
Read 7 tweets
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24 Oct
A lot of new data out on treatments for COVID-19. Updating a previous thread with what we know now. Still lots of research ongoing and a few things may change. Much of this world leading research is taking place in the UK, funded and delivered by @NIHRresearch. 1/20
Dexamethasone: A simple steroid drug widely used in many diseases. Shown in @NIHRresearch RECOVERY trial to improve survival for respiratory failure due to COVID-19 (i.e. severe cases only). Probably acts by reducing lung inflammation. 2/20
Hydrocortisone: Another widely used steroid drug. May help systemic (whole body) inflammation in critical (life threatening) illness which some call 'cytokine storm'. @NIHRresearch funded @remap_cap trial suggests benefit in ICU patients but weaker signal than dexamethasone. 3/20
Read 20 tweets

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