• 10 Dec 2020
  • 14 min 58
  • 10 Dec 2020
  • 14 min 58

In this episode NPS MedicineWise CEO Adj A/Prof Steve Morris catches up with Executive Director of the National COVID-19 Clinical Evidence Taskforce A/Prof Julian Elliott. They discuss how 2020 played out in terms of the top medicines that were touted as treatments for COVID-19, the emerging areas of evidence, and how clinicians on the ground have been applying the living guidelines.


Further reading

The National COVID-19 Clinical Evidence Taskforce and its Living Guidelines: https://covid19evidence.net.au/

NPS MedicineWise COVID-19 information hub: www.nps.org.au/coronavirus

Transcript

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Steve Morris:

Hi, I'm Steve Morris, CEO of NPS MedicineWise, and I'm pleased to once again be joined by Executive Director of the National COVID-19 Clinical Evidence Taskforce, Associate Professor Julian Elliot. Welcome, Julian.

Julian Elliott:

Thanks, Steve. It's a pleasure to be here again.

Steve Morris:

Well, Julian, last time we had you on this podcast, I think it's way back in June now, we talked about the role of the Clinical Evidence Taskforce during this pandemic, and the role of living evidence and guidelines, and recent and upcoming clinical topics to be covered by the taskforce. And at that point, I think NPS MedicineWise had just joined the taskforce as a partner.

So look, seven months later, I was really keen firstly to do a quick rundown on some of the medicines that have been touted as disease modifying treatments, and in some cases cures, along the way for COVID-19. So maybe just in a sentence or two, if you could Julian, just run us past the current evidence-based thoughts on hydroxychloroquine, remdesivir, dexamethasone, zinc and vitamin D if you could.

Julian Elliott:

That's quite a list. Absolutely. So in terms of hydroxychloroquine, there's now actually quite substantial randomised data that gives us confidence that it is not effective for the treatment of COVID-19. We have left some scope for the use of hydroxychloroquine in trials for chemoprophylaxis, because we believe that further data there may help to clarify the picture. But certainly for treatment, we have a high degree of confidence that additional information will not change the recommendation not to use hydroxychloroquine.

For remdesivir it's actually an interesting time as the World Health Organization have just issued recommendations not supporting its use in people with COVID-19. We continue to have a recommendation, a conditional recommendation, that clinicians can consider using remdesivir for people who are hospitalised, who require oxygen but not ventilation. That's based on our view of the collective randomised controlled data to date. This really comes down to a methodological question around looking at the subgroups that were included in the trials of remdesivir.

So the World Health Organization panel has taken a particular view, particularly in the context of the use of remdesivir across the world, including in low and middle income countries. And we're in conversation with the WHO show just to clarify the exact points that contributed to their view, but we are at present going through a process of just reviewing that approach and making sure there's nothing there that we've missed. But at the moment, our recommendation stands to consider using remdesivir in adults who are hospitalised, who require oxygen but not ventilation.

So for steroids ... Yeah, so I think perhaps when we last spoke the data was largely for dexamethasone, but now with the report of additional trials, including REMAP-CAP, which is an Australian-led platform trial, we now are able to issue recommendations regarding corticosteroids in general. So we have a recommendation to use dexamethasone in adults with COVID-19 who are receiving oxygen, including those who are ventilated. Also, there are alternative corticosteroids which can also be considered. So the strongest evidence is for dexamethasone, but other steroids that could be considered include hydrocortisone, prednisolone, and also methylprednisone.

For zinc and vitamin D ... We issue recommendations once we have identified randomised controlled trial data. And so to date we do not have any recommendation regarding zinc, and we also do not yet have any formal recommendations regarding vitamin D. So we're aware that there's still more research to be conducted to support or refute the use of those agents for COVID-19.

Steve Morris:

Yeah. Thanks. I think it's really useful for our listeners to have that reiteration of where we now currently sit given obviously the emerging evidence and evaluation of that evidence over the last seven months. In terms of, I suppose, additional emerging areas of research, is there anything you're keeping a close eye on at the moment?

Julian Elliott:

Yeah, so I think that one thing perhaps for your listeners to be aware of is that up until date, we have largely not tackled areas around infection prevention control. We've been working quite closely with the national group that is responsible for guidelines in that area. So that's the Infection Control Expert Group, or ICEG. And in the last couple of months we've had a pilot partnership project with them looking at CPR. Infection control is an important consideration for anyone giving CPR, as you might imagine, during the pandemic. And so that was a set of clinical flow charts that we produced in collaboration with ICEG.

That went very well. Then the Commonwealth government has now asked us to get more deeply involved in infection prevention and control topics. And so we've actually recently established a new panel, which we imagine will be announced any day now, which will be tackling some of the core issues around infection prevention control in clinical settings, including hospitals, primary care clinics and aged care.

So that's certainly quite a substantial step for us as a taskforce, beginning to look at those sets of issues. Many of your listeners, I'm sure, are aware that there's been a lot of controversy. So we don't underestimate the challenges of developing evidence-based guidelines in those areas, but it is certainly a very important area. So we're going to bring a lot of attention and resource to addressing those issues. In addition, the ... Well, we just talked about drug treatment. Drug treatment continues to be a very active area. It's probably our most active panel and we expect that to continue right through 2021. So whilst Australia can be very pleased with the position we're in at the moment we, from day one, have always continued our work regardless of the fluctuating numbers, because a lot of what we're doing is about preparedness. Making sure that we're constantly up to date so that whenever there is an outbreak or further cases, Australian clinicians do have the resources they need.

So certainly drug treatment will continue to be a very active area, I think. We did an estimate recently and it's really only a very small percentage of all the trials registered that have reported that [inaudible 00:07:54] something like 10% or so. So there's still many hundreds of drug trials, and we'll be continuing to monitor them. And then the final area is around post-acute COVID syndromes. There is clearly a number of people who suffer fairly debilitating ongoing effects after the COVID acute disease. Of course, we've seen previously in many other infectious diseases these kind of post-infective syndromes. We are aware that there's not a lot of very high quality data so far regarding prevalence of these symptoms, nor really any data so far regarding effective interventions, but that's certainly another area that we're going to be watching very carefully.

Steve Morris:

Thank you for that. Obviously there's not a lack of issues to be looked into and addressed. And looking just in terms of, I suppose, feedback you may have received for the guidelines that you've produced, have you heard from conditions on the ground how they're applying your living guidelines in practice?

Julian Elliott:

Oh yeah, absolutely. We have been running surveys of clinicians, and more recently we've done a more formal impact evaluation. That's all still underway, but I think what we're finding is that really clinicians all over Australia have been using the guidelines, either directly or to develop their own local protocols for their own clinic or hospital or health service. I guess the summary would be that the guidelines have been used in a variety of ways, that they've been used where people have been seeing patients with COVID, but also in other areas so that people are prepared and feel like they're prepared.

So there's an important element here about people having a sense of confidence about a single source of truth and a single place they can go to, which I think helps to alleviate some of the anxiety and helps clinicians to feel more confident and comfortable managing people with COVID-19. And I think what we're finding is that people really value this combination of the guidelines being comprehensive, being trustworthy as based on very rigorous processes, but also up-to-date, and incorporating the experience of many of Australia's leading clinicians in this space. We've had clinicians say things such as, "It made me feel like I wasn't alone," or, "Knowing that people were looking into the evidence, I felt supported." So there's, I think, a very important element of this that is about reassurance.

Steve Morris:

That's fantastic feedback, Julian. And obviously given the challenge that you are faced with and the short timeframes, are there any lessons that you can reflect on? Lessons that you've learnt in the process to date?

Julian Elliott:

I think there's a number of lessons. I think the first thing to say is that we've really demonstrated that you can create rigorous national guidelines and update them weekly. That hasn't been done before, anywhere in the world. I think many people would have thought we were somewhat insane taking on [inaudible 00:11:21] this process. And it certainly has taken quite a lot of very strong project management really to make the process run. But in the end, it does run. And it is about breaking the work up into bite-sized pieces. We need to move quickly each week to make sure we update, but it means that the amount of evidence we're having to review each week is feasible. So that's certainly one of the lessons.

I think the other is that the foundation of the partnership that is the taskforce is really everything. We now have 32 national clinical groups as members of the taskforce. And I think as we mentioned in the last podcast, the model we use is that each week we seek a hundred percent consensus from all those 32 organisations before we update our recommendations. Again, that may sound like a form of insanity, but it actually does work, and we've been incredibly grateful and impressed by the openness for our partner organisations to work differently, to move much faster than we all did pre-pandemic. So I think that's, again, a very important lesson that you can achieve really strong consensus across a number of stakeholder groups if you get the model right.

I think the other things are that we ... Our focus really is on clinicians and making sure clinicians have that single source of truth. But I think we're also just become aware of how important it is for us to also engage with the general media. There's been a lot of controversy roiling around the general media over the course of the pandemic, and I think that's been very confusing to many people in the general public. So we've tried to provide a trustworthy voice, I guess, so that people can understand what the evidence does actually say and what it doesn't say.

Steve Morris:

Yeah. Thanks, Julian. Is there any final message or area you want to talk to our listeners about?

Julian Elliott:

Oh, I guess I would just take the opportunity to thank you, Steve, and NPS. I think it's been a great partnership so far. The assistance that NPS MedicineWise has been providing on dissemination I think has been fantastic. And really we could not have got the message out as broadly without your organisation. I think that, going forward, really one of the things we want to build on further is that element of dissemination and translation, and then monitoring uptake and use. That's obviously an important part of the evidence cycle. We've done a bit on that, but with time and resources and things that's been somewhat limited. So we're quite keen to extend that further.

Steve Morris:

Yeah. Thanks, Julian. And thanks to the taskforce for all you've done, as you said a few minutes ago, to make sure that clinicians don't feel alone and providing a single source of truth, which has been really important over the last several months. So thank you and thank you to your organisation.

Julian Elliott:

Not at all.

Steve Morris:

All right. Well, thanks for listening. And if you require any further information, you can go to the NPS website. Thank you.

Voiceover:

For more information about the safe and wise use of medicines visit the NPS MedicineWise website at nps.org.au.