Just published in @BMJ_latest, an update to our @WHO living guideline on drugs for #COVID19 – this update focuses on #remdesivir & was informed by the results of 4 trials w/7,333 participants – ACTT-1, SOLIDARITY, Spinner (JAMA), & Wang (Lancet). tinyurl.com/y4svlcyn
Summary: based on currently available data, there is insufficient evidence that #remdesivir improves patient-important outcomes ➡️ thus, a conditional (weak) recommendation against the use of remdesivir in hospitalized patients with #COVID19.
A conditional, or weak, recommendation against #remdesivir means that, based on current data, the undesirable effects probably outweigh the desirable effects, but substantial uncertainty exists. With this in mind, we very much felt that trials of remdesivir should continue.
When making this recommendation, outcomes thought to be most important were:

1. Mortality
2. Need for & duration of mechanical ventilation
3. Time to clinical improvement
4. Treatment-related serious adverse events.

We also considered factors such as resources & feasibility.
One concern was the importance of not drawing resources away from best supportive care – staff & resource limitations have already been issues throughout the #pandemic. It’s not exciting to talk about best supportive care, but no medication will be effective in its absence.
Many areas of uncertainty remain & it's not clear that #remdesivir is ineffective. Do specific groups of patients benefit? Would #steroids impact the results? The mortality benefit of steroids hadn’t yet been established during much of the time remdesivir trials were enrolling.
Research is continuing & evidence has been evolving at a rapid pace. Our update is part of a living guideline, which will continue to be updated as we learn more about therapies for #COVID19. And as always, it was an honor working on this guideline w/ so many outstanding people.

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More from @NidaQadirMD

6 Oct
#CCCF2020 Brian Kavanaugh Controversies - #COVID19: #ARDS or not? What we really addressed - not so much "is it ARDS?" but rather, "does it matter?" So happy to have been a part of this, but man, I still have so much to say! My take on the ? – yes, it matters - to an extent 🧵 1/
Pre-intubation management: YES, but not because it substantially changes methods of support, or the criteria used for #intubation. It matters because categorizing patients as having #ARDS has value. 2/
If we use the Berlin definition, patients on Venturi masks or arguably #HFNC don’t actually meet criteria for #ARDS because they’re not on PEEP >/= 5. The natural history of ARDS though almost certainly begins prior to the use of mechanical ventilation (invasive or not). 3/
Read 13 tweets
25 May
Some more #COVIDDeepThoughts after post-ICU clinic this week. All of the patients we saw were #COVID19 survivors in their 40s-60s, previously relatively healthy, had been intubated in the #ICU, some for quite a while. 1st, the good news. All of them were home & many back at work.
We had done a lot of video visits beforehand, which made things go much more smoothly...because of the video visits, many patients had gotten medication adjustments and subspecialist referrals they needed before seeing us in person.
Observations: Everyone experienced delirium in the #ICU, even those w/o OVERT delirium...ppl w/ neg CAM-ICU, RASS 0, interacting seemingly appropriately. Important to ask about this...I took care of almost all of these pts myself in the ICU & wouldn’t have known if I didn’t ask.
Read 9 tweets
4 May
I don’t like posting depressing posts but I think it’s time. When this all began, I would walk into the #COVID unit with the energy of a #hype man at a #hiphop show. I hate COVID19 but I love being an #ICU doctor & getting people better. Today I am mentally & physically exhausted
Other than my AM commute, I’ve seen daylight only once this week - today when I had a few minutes for a #coffee break. Today was also the first time I got home before 10 pm, but before I even had a chance to take my #decontamination shower...
I got called about yet another complex #COVID admission by my even more hard-working #PCCM fellows. The amount of face-to-face time required to take good care of these patients cannot be truly appreciated unless you’ve worked in an #ICU. The days are long & the work is relentless
Read 7 tweets
26 Apr
The past few days have included a lot of thoughtful debate/discussion about #COVID19 and #ARDS, some snark (of which I too am guilty), and a hefty dose of HOW DARE YOU CHALLENGE A MASTER, YOUR RIGIDITY IS KILLING PEOPLE. I have a few things to say. Bear with me as I ramble a bit.
The idea that #EvidenceBasedMedicine does not allow for individualization for specific patients and changes in their clinical courses is a fallacy. Certain concepts that are known to save lives can & should be adhered to in a manner that is appropriate for the individual patient.
I thought this was obvious but that clearly is not everyone’s interpretation of #EBM. Also lung-protective ventilation does not = set it and forget it. Settings needed to maintain LPV will obviously change during a patient's course, something that experienced clinicians know.
Read 13 tweets
15 Apr
Some #COVIDDeepThoughts / reflections on clinical care in the #COVID #ICU now that I’ve had a chance to slow down a bit. It seems like a lot of folks are reaching for explanations for why #COVID19-related respiratory failure is something different & exotic & somehow not #ARDS.
As a result, a lot of pretty out there treatments with significant risks and downsides associated with them are being suggested by physicians, many of whom did not regularly care for #ARDS patients pre-#COVID19. These are being hyped up in the press & families are asking for them
I get it, it’s a lot less exciting to say “the patient recovered from #COVID19 w/ meticulous supportive #ARDS care” than it is to say “I did this weird new thing or gave this specific drug & the patient miraculously got better.” But #fundamentals >>> hype & unproven therapies
Read 8 tweets

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