Three Longs & Three Shorts

Interview: ‘Remdesivir doesn’t save lives – but desperate families demand that doctors prescribe it’

Fear and panic trigger irrational behaviour. Truth be told those of us who earn a living in the financial markets basically train ourselves to thrive when others are panicking. It is in that context that we become hyper-sensitive to signs of fear and panic in the society that we live in. The tragic panic-stricken rush of tens of thousands of families who have been running around Maharashtra seeking Remdesivir for their loved ones is an indictment of our society at many levels as Dr Lancelot Pinto, consultant pulmonologist at Mumbai’s PD Hinduja Hospital, explains in this interview with Smitha Nair. Firstly, does the drug work. Here is Dr Pinto’s clear answer: “The message from multiple studies (and a systematic review which included over 7,000 patients conducted as a collaborative effort commissioned by the WHO) is clear and consistent about remdesivir: neither does it reduce mortality (i.e. it is not “life-saving”), nor does it prevent the clinical worsening of a patient to the point of being on a ventilator (i.e. it does not prevent mild/moderate disease from becoming severe).” Secondly, if Remdesivir doesn’t work then why are doctors in Maharashtra sending the relatives of Covid-19 patients on a hapless hunt for this drug? Dr Pinto again: “Based on the World Health Organisation solidarity trial results and three other Randomised Control Trials, the WHO issued a conditional recommendation against the use of remdesivir late last year. As recently as last week, WHO chief scientist, Dr Soumya Swaminathan, reiterated that position. Smaller studies, like this study published in NEJM concluded that their data shows that remdesivir was superior to placebos in shortening the time to recovery in adults who were hospitalised with Covid-19 and had evidence of lower respiratory tract infection….. The only possible role it may have is in reducing the length of stay in a hospital, and this has been touted as a strong reason to use it, especially when hospital beds are in shortage, and discharging a patient as soon as possible is of paramount importance. But this is a very nuanced argument, and is applicable to countries/settings in which admission criteria are very stringent. If, for example, a person does not need to be hospitalised, or is being hospitalised only to receive remdesivir, not only is the drug unlikely to have an effect, the decision to administer remdesivir could potentially make a bed unavailable for five days [the length of a course of remdesivir]. Same argument holds true for a patient who is fit to be discharged from the hospital in two or three days but is now committed to being in the hospital for five days because of being prescribed remdesivir. What also seems to be the consensus is that if the drug does have an effect, it is more likely to do so in the early, viremic phase of the disease than the later phases. The only situation in which I would use the drug is when a high-risk individual with early viremic symptoms is admitted in view of the high-risk. Once a patient’s oxygen levels have fallen (usually in the second week of the disease), the drug is unlikely to be of any use. Unfortunately, most of the cries for help are for patients in this stage of the disease. The desperation is understandable, but the need to “do something” does not warrant using drugs that have been clearly proven to be ineffective.” Thirdly, how did we get here? Why is it that a year into the pandemic our treatment protocols are not based on evidence-based science? Dr Pinto: “Drugs such as favipiravir, HCQ, itolizumab, and a whole gamut of vitamins and antibiotics are present in the Maharashtra task force recommendations, which were updated as recently as March 23. These drugs, to the best of my knowledge, are included in the guidelines of no other country in the world. I have a collection of prescriptions from patients who have taken a second opinion from me, which have close to a dozen drugs for mild and asymptomatic Covid-19 being managed at home. It becomes a daily struggle for physicians who practice sound evidence-based medicine to counter the demands of patients when task forces recommend the contrary.”