Why is there a shortage of Remdesivir, with family members desperately trying to procure it when it has been proven that it is no better than routine care? #EvidenceBasedMedicine
There are two living meta analysis and systematic reviews that show it is not better than routine care. Close to 4000 patients in randomized trials showing no benefit, and patients & families desperate and buying in the black market because they believe it will save their patient
Wow! This tweet seems to have stirred up a lot of interest (and violent reactions). I'm glad there has been (some) discussion about the science, and the evidence, and justifiable disagreement. We've had experienced experts in the field weighing in, and I respect those views
Some part of this discussion however, seem to have degenerated into personal attacks, and that is disappointing. We are all mature adults, and we can well agree to disagree.
First, the reality. What provoked this tweet was the hundreds of patients' families running from pharmacy to pharmacy trying to source Remdesivir. The current blackmarket price is Rs 4 to 5000 and in some places Rs 12 to 15000 (price cap at Rs 1400; actual price closer to Rs 700)
While theoretically possible, it is unlikely that all these patients fit into the criteria where the experts seem to believe there is benefit. What this does is actually quite cruel...
In the event that the patient dies after the family could not source Remdesivir, it puts the burden of guilt squarely on the family, leaving them with "If only I had tried harder (or paid more) to get it, maybe our loved one would still be alive"
This is cruel
Second, the evidence - the two largest trials - RECOVERY and SOLIDARITY - both failed to show a difference in outcomes between Remdesivir and routine care. Does this rule out subsets where this may be effective? No
But prescribing it indiscriminately is not exactly evidence-based
I still agree with the possibility that there may be subsets where this will work. That was not the point of my tweet. I quite enjoyed the scientific arguments put forth. What was disappointing were some of the arguments...
Argument 1. Our clinical decisions cannot be dictated by RCTs alone.
I agree, but only partially. We do need to exercise clinical judgement combined with the data, but if we allow clinical judgement to overshadow data from RCTs, we are going down a very slippery slope
This is especially true in a disease like #COVID_19 where the vast majority of patients ultimately recover. If you were to give any drug to someone with COVID, there is a 98% chance that the patient will recover. The important point here is that it doesn't prove the drug works.
With a 98% recovery rate, crediting whatever drug you gave for the recovery is unwise, and certainly not the right decision for the next 100 patients with COVID that you treat. Which is why the reliance on RCTs and level 1 evidence.
Argument 2: "He got it wrong with #Tocilizumab in Oct 2020, so he's wrong here too."
Poor argument. There was no evidence to support Tocili in Oct 2020. There is now - I agree now that it has its role in specific indications...
But that doesn't change the fact that in Oct'20, we didn't have data. That's how science progresses. You get new data, and you change your mind - that is why having an open mind is so important for a researcher. Using that as an argument to question someone's credibility is weak
Argument(s) 3: a) You cannot argue with 'x' because he is so "well-known"
Though this was made to support my tweet, I disagree with this - what is important is the content, and not the person who has the opinion. I refuse to use my position to legitimize my statements
Argument(s) 3: b) Stay in your lane - you are an oncologist, and you can't speak about COVID treatment
Again, I disagree - if we had to be ID experts to comment on #COVID_19, the discourse over the past year would have been unidimensional and poor
And importantly, the assumptions that were made. That being an oncology centre, we didn't treat COVID. That's not true at all.
Responding to the magnitude of the pandemic, on request from the government, and being a responsible public hospital, Tata Memorial (in spite of being a dedicated cancer centre) has been treating COVID over the past year, at one point with 170 beds dedicated for COVID treatment
We have treated thousands of patients with COVID over the past year; and we did this while continuing to treat all our patients with cancer. I hope this clarifies things and we are able to accept disagreements without being disagreeable. Stay safe, folks.

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More from @cspramesh

27 Feb
Let me tell you an amazing story...
In the 1990s, a maverick breast surgeon at @TataMemorial (fresh from his return from the UK) stepped up to do research. Now, to understand the situation, you should go back 30 years, when research was not as big as it is now, and certainly not from surgeons.
Surgeons, and especially cancer surgeons, were renowned for their technical prowess, and their sheer bravado – "wherever the cancer, however advanced, I will take it out". So, our surgeon-researcher was ridiculed for even attempting clinical research
Read 18 tweets
29 Jan
Great work by Connor Wells & Shubham Sharma @QueensUHealth asking two important #GlobalHealth questions
1. Is there a #publicationbias against papers from #LMICs?
2. Do oncology RCTs match the global disease burden?
Confirms something we always knew
What we did was this...
We identified 3 problems and 2 facts
We looked at all phase 3 studies in oncology from 2014 to 2017; classified origin of these RCTs based on #WorldBank economic classification of countries. We compared RCT designs and results from HICs and LMICs. The findings were striking…
Of 694 RCTs, 636(92%) were led by HICs; 58(8%) by LMICs. This is the first problem – huge imbalance in where research is done. Cancer incidence is strikingly different in HICs & LMICs, with considerable burden in LMICs. How can we accept such a skewed distribution of research?
Read 10 tweets
25 Dec 20
The WHO’s chief scientist on a year of loss and learning nature.com/articles/d4158…
For anyone remotely involved in healthcare, these are life lessons from @doctorsoumya. A must read.
For those of you who want a quick analysis, thread.
Disclaimer: I’m just breaking this up & annotating them with my own comments. Between quotes are her exact words (with some poetic license)
Planning ahead & prioritizing first steps – an important aspect of taking up a new job
“My original plan for 2020 included rolling out new processes to ensure the quality of technical documents, such as guidelines on water quality, tobacco advertising and immunization programmes”
Read 23 tweets
17 Oct 20
The preprints of the #SOLIDARITY trial are out on MedRxiv. While many may lament that all four drugs tested did not show benefit, this is a remarkable trial for many reasons. Thread
First, this was another #MultiArmMultiStage #MAMS study design; @MRCCTU made this highly efficient trial design globally acclaimed with #STAMPEDE. The more recent #RECOVERY trial was another example of this.
@MaxParmarMRCUCL @Prof_Nick_James @PeterHorby @MartinLandray
What the #MAMS design does is enable testing multiple drugs simultaneously, flexibility to drop unpromising ones & add new promising ones even midway during the trial. This was crucial in the #COVID__19 pandemic where the situation has been constantly evolving
Read 16 tweets
12 Sep 20
I’ve been watching with increasing concern at the trend of new daily diagnoses of COVID-19 in India over the past two weeks. To me, this reflects general public mood which seems to have begun to ignore the threat this virus poses. Thread
While the good news is that our death rates haven’t been as bad as some of the other countries (we might debate the accuracy of death reporting), but with a population of 1.35 billion people, the absolute numbers are still sobering. And rural India is just beginning to get hit
What I’d like to see is reliable “Excess mortality” and a P score which will quantify the true impact of the pandemic on deaths in India. We know that Mumbai had an excess mortality of 13000 deaths between Apr and Jul 2020. We don’t yet have data for India as a whole.
Read 23 tweets
24 Aug 20
I can't believe the @US_FDA Commissioner @SteveFDA announced that 35 out of 100 patients treated with #ConvalescentPlasma will benefit from it. This demonstrates either a lack of understanding of basic statistics (relative risk vs absolute risk) or external pressures. (1/n)
There are several problems with this - first, this is not based on randomized evidence. This is based on "data obtained from the ongoing National Expanded Access Treatment Protocol (EAP) sponsored by the Mayo Clinic". The preprint is available on medrxiv.org/content/10.110… (2/n)
In an observational study of 35,322 patients transfused with CP, 7-day mortality was 8.7% in those where CP was transfused early (3 days or less) and 11.9% in those transfused later (>3 days). 30 day mortality was 21.6% vs 26.7%. (3/n)
Read 13 tweets

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