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Rupert Pearse

13 Jan, 9 tweets, 4 min read

@remap_cap

Recent trial results show some promise for Tocilizumab in the treatment of severe COVID-19. Welcome news at a difficult time and excellent work from @remap_cap & @NIHRresearch. But the results raise some difficult issues for doctors treating patients. 1/9

https://twitter.com/NIHRresearch/status/1347221239446831106?s=20

To recap, Tociluzimab is normally used to treat inflammatory arthritis and other immune disorders. The drug suppresses the systemic (whole-body) inflammation (AKA 'cytokine storm') and may reduce the harm of COVID-19 especially for critically ill patients. 2/9

@The_MRC

Scientists from @The_MRC population health sciences unit combined data (meta-analysis) from 2107 patients in six trials including @remap_cap. The results suggest a small reduction in 28-day mortality. But most of the benefit was from REMAP-CAP. The results are not clear cut. 3/9

@remap_cap

Trials in critically ill patients are hard to do and @remap_cap includes only 353 patients. But the much larger RECOVERY trial has >3000 patients in the tocilizumab arm and is still recruiting. RECOVERY data will be very important in deciding the overall value of tocilizumab. 4/9

@remap_cap

We can compare the designs of these trials but for my money, the trial populations are pretty similar. The big difference is @remap_cap uses a different type of statistics (Bayesian) to the others and this may alter how strict we are in deciding whether the drug works. 5/9

Clearly, we must review all the trial data together. We cannot simply pick and choose the trial we like best. Happily, the RECOVERY trial will probably be completed in only a few weeks. But what should doctors do while we wait for the RECOVERY results…? 6/9

….should doctors enrol patients in the RECOVERY trial so we get those results sooner, or should we give our patients tocilizumab now based the results of just one trial of 353 patients. The situation creates a moral dilemma for doctors on the frontline. 7/9

@NICEComms

Some important lessons here for researchers in how they work together to publish trial findings. Meanwhile we must wait 2-3 weeks for @NICEComms to guide us. The best solution is probably to recruit to the RECOVERY trial where we can and whenever our patients agree. 8/9

Most importantly, tocilizumab is NOT a cure for COVID-19 although it may help. but this benefit needs to outweigh any harm from the drug. We are worried that immunosuppression may lead to other infections. Only with the RECOVERY trial results will we finally know for sure. 9/9

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More from @rupert_pearse

Rupert Pearse

@rupert_pearse

14 Jan

The number of new coronavirus infections may be levelling off, but patient admissions to NHS hospitals for COVID-19 will increase for another 7-10 days. The question of how we choose which patient gets an ICU bed is now a routine one in media interviews. Doctors are worried. 1/11

The burden of decision making around ICU admission traditionally falls on senior ICU doctors. Most of us are privately very worried about what will happen if we run out of resources. The false suggestion that we rationed ICU beds in the first wave has upset a lot of people. 2/11

To be clear, I am not aware of ANY patient who was not admitted to intensive care during the pandemic when the ICU consultants responsible believed that they should be. But we would be failing in our duty if we do not plan for this situation. 3/11

Read 11 tweets

Rupert Pearse

@rupert_pearse

9 Jan

The vaccine conversation took an unexpected turn this week with the decision to prioritise first doses for people who haven't been vaccinated over second doses for those who have. Staff who all year have worked in COVID zones are now preoccupied with their immunity status. 1/8

This has turned out to be a very emotive issue for NHS staff. The topic has split us along invisible fault lines. In some cases, our position in the vaccination queue (and that of people we care about) seems to define our views on the science. 2/8

I'm not expert in the science but listening to those who are, delaying the second dose seems a legitimate thing to debate. Technical discussion revolves around how long the 2nd dose could be delayed and how much difference this might make make, as opposed to a binary debate. 3/8

Read 8 tweets

Rupert Pearse

@rupert_pearse

5 Jan

Why did we need a lockdown? For many people, their lives have not (yet) been touched by COVID as an illness – only by public health measures. But we need a lockdown to protect everyone’s healthcare, even those who aren’t ill. Here's why... 1/8

NHS hospitals are under extreme pressure. We now have more than 21,000 hospitalised patients with COVID-19. This number continues to rise and will carry on rising for most of January. Many of these patients will need to stay in hospital for several weeks. 2/8

The NHS cannot and will not turn emergency patients away. We treat every patient who comes to hospital. But when hospitals fill with emergency patients, there is always an impact on elective (planned) care. This often happens in Winter but is far far worse this year. 3/8

Read 8 tweets

Rupert Pearse

@rupert_pearse

31 Dec 20

Media reports of pressures on the NHS are all true. The situation in London is now MUCH worse than the first wave, and still deteriorating. Sad to see long queues of ambulances outside the hospital where I work. Re-visiting reasons for hope and also words of caution…. 1/10

1. We understand the disease: The baptism of fire in the spring taught us how COVID-19 behaves. NHS teams have reflected on what worked and what didn’t. For example, we know we will see problems like blood clots and kidney damage more often than usual. 2/10

@NIHRresearch

2. Treatments are more focused: The media furore around wonder drugs was a massive distraction but @NIHRresearch and others have rapidly delivered major clinical trials which busted a few myths eg hydroxychloroquine and showed simple things can save lives eg dexamethasone. 3/10

Read 11 tweets

Rupert Pearse

@rupert_pearse

24 Dec 20

Situation in London continuing to deteriorate as expected. Many doctors are worried that other parts of the UK will follow. A lot of misinformation around, so some fairly blunt observations here, for which I apologise. But we all need to understand the equation. 1/10

As with the first wave, the sharp rise in people testing positive for SARS-CoV-2, will be followed by a sharp rise in hospital admissions for COVID-19, and then a similar rise in excess deaths in January.... 2/10

….but like all disasters, for every death we can expect many more people to be injured and survive. And so it is with COVID-19. Most hospitalised patients will survive but they will take a long time to recover. Many will experience so-called ‘Long COVID’. 3/10

Read 10 tweets

Rupert Pearse

@rupert_pearse

22 Dec 20

News of the lockdown was greeted with grim relief by NHS staff on Saturday. On the one hand, it will ease the pressure on hospitals affected by COVID-19. On the other, everyone’s Christmas is affected including NHS staff, many of whom live away from their families. 1/5

NHS hospitals are under huge pressure and expect to remain so until well into January. The number of people testing positive for the virus SARS-CoV-2 has risen sharply and so have hospital admissions with the disease COVID-19. 2/5

The south-east England and south Wales are worst affected but now some areas of the midlands are seeing high numbers of positive tests as well. With news that the new virus mutation is more infectious, we should prepare for a rebound rise across the UK. 3/5

Read 5 tweets

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