Medical Trial and Error is Keeping Patients Alive.
On June 7, 2020, The Wall Street Journal Editorial Board reported on the findings of recent studies that cite that Covid-19 has become less lethal over the past few months, entirely as a result of improvements in treatment protocols as clinicians utilize pre-clinical data.
The following is a reprint of the WSJ's Coronavirus Good News.
"Good news: A new study finds that the novel coronavirus has become less lethal over the past few months. While there’s no evidence that mutations are making the virus less deadly, treatments have improved enormously as scientists have learned more.
Doctors have observed that the coronavirus case-fatality rate seems to have decreased considerably since the early days of the pandemic. But a pre-publication study from Italian universities and local public-health authorities comparing the case-fatality rates in two provinces (Ferrara and Pescara) during March and April is the first to show this might be true.
After adjusting for age and comorbidities, the study found the overall death rate declined by some 40% from March to April with huge reductions in those over age 80 (from 36.3% to 16.1%), and subjects with hypertension (23% to 12.1%), diabetes (30.3% to 8.4%), cardiovascular disease (31.5% to 12.1%), COPD (29.7% to 11.4%) and renal disease (32.3% to 11.5%).
The study’s findings need to be confirmed by more studies of fatality rates over time in other places. But the researchers note that the decline in death rates is unlikely to be due to less crowded hospitals since infection rates were low in the two provinces and never exceeded the intensive care unit capacity. Hospital utilization could confound results in other hot spots.
They say their study confirms anecdotes from expert physicians that “the early administration of more tailored medications, is considerably improving the clinical course of COVID-19.” Doctors are using a cocktail of targeted therapies including repurposed HIV antivirals, anticoagulants and monoclonal antibodies like tocilizumab that lower inflammatory cytokine attacks on organs.
A European Journal of Internal Medicine study last month found that two of 62 patients receiving tocilizumab died compared to 11 of 23 in a group with similar characteristics. Randomized clinical trials are needed to draw solid conclusions about the efficacy of drug treatments, but they usually take months. So doctors have been experimenting and learning on the fly.
We now know, for instance, that deaths among severely ill patients often result from an overreactive immune response known as “cytokine storms” as well as systemic blood clots. The Food and Drug Administration this week approved a new blood test by Roche that measures levels of the inflammatory-causing protein interleukin-6 and can help predict patients at risk for cytokine storms. Using drugs to break up blood clots and calm down the immune system earlier can prevent severe cases from turning deadly.
Doctors have also observed that some patients with fatally low oxygen levels aren’t gasping for air or losing consciousness and their symptoms resemble altitude sickness—dizziness, nausea and headaches—more than pneumonia or acute respiratory distress. As a result they are using less intensive ventilation such as nasal cannulas and sleep-apnea machines.
Mechanical ventilators can cause long-term brain and respiratory damage as well as secondary infections. A study in the Journal of the American Medical Association has found that a shockingly high 80% of those between ages 18 and 65 who were placed on ventilators in New York City died while just 2.4% were discharged alive during the study period. More targeted therapeutics can reduce the need for ventilators.
The FDA last month approved Gilead’s antiviral remdesivir for emergency use after a phase-one trial found that the drug reduced recovery times in hospitalized patients on average to 11 days compared to 15 days for those in a control group. Remdesivir stops the virus from replicating, so it may be even more beneficial if administered earlier in the illness.