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UPMC: Trial shows improvements in very ill coronavirus patients

UPMC clinician-scientists, in collaboration with 121 hospitals in eight countries, have found that inexpensive, widely available steroids can be used to improve the odds of survival for very sick COVID-19 patients.

On Thursday, UPMC held an online press conference with Dr. Derek Angus, UPMC chief health care innovation officer and chair of critical care medicine at the University of Pittsburgh; Dr. Oscar Marroquin, UPMC chief health care data and analytics officer; and Dr. Donald Yealy, UPMC senior medical director and chair of the Emergency Medicine Department at UPMC and the University of Pittsburgh; to discuss the Randomized Embedded Multifactorial Adaptive Platform-Community Acquired Pneumonia (REMAP-CAP) corticosteroid trial.

Angus said the positive news from the trial is that hydrocortisone, a type of corticosteroid, reduces the odds of death and the use of life support for critically ill COVID-19 patients. He said the results of the trial caused the World Health Organization to issue new health guidelines for the use of corticosteroids.

Between March and June, the REMAP-CAP corticosteroid trial randomized 403 adult COVID-19 patients admitted to an intensive care unit to receive the steroid hydrocortisone or no steroids at all. The trial found a 93% probability that giving patients a seven-day intravenous course of hydrocortisone would result in better outcomes than not giving the steroid. The results were consistent across age, race and sex.

“It is relatively rare in medicine that you find drugs where the evidence of their effectiveness in saving lives is so consistent,” Angus said. “This is, in many respects, the single clearest answer we’ve had so far on how to manage terribly ill COVID-19 patients. People on ventilators or oxygen and under intensive care should definitely be given corticosteroids.”

REMAP-CAP included the UPMC-REMAP-COVID19 trial, the only U.S.-based trial to test corticosteroids — a class of drug that lowers inflammation and modulates immune system activity — for treating critically ill COVID-19 patients. An analysis combining the REMAP-CAP data with that from six other randomized controlled trials to test corticosteroids reinforces the results of the UK trial called Recovery that was reported in June, which found the steroid dexamethasone reduced deaths by 29% in ventilated COVID-19 patients.

REMAP-CAP and the other corticosteroid trials did not test the drugs in non-hospitalized patients with COVID-19 who did not need respiratory support. Steroids currently are not recommended for these patients because they can dampen the immune system and have serious side effects.

Because it is designed to simultaneously test multiple combinations of potential therapies — as opposed to the traditional, slow clinical trial process that tests one therapy at a time — REMAP-CAP is particularly well-suited for rapidly identifying effective treatments during the COVID-19 pandemic. It currently is testing thousands of different treatment regimens, including various doses and combinations of vitamin C, convalescent plasma, blood thinners, antivirals and immune modulators.

COVID-19 DEATH RATES CONTINUE TO DECREASE

Yealy discussed how the amount of time spent in a hospital, intensive care patients, use of ventilators and death rates continue to lower in COVID-19 patients compared to the results in March and April. He said the better results are because of better treatments, including the use of steroids, and better medical protocols that are now being used as the UPMC medical staff grows in experience in dealing with the coronavirus.

“It shows we can impact this infection with our actions,” he said. “COVID-19 patients are doing far better now than at the start of the pandemic.”

Marroquin said daily discharges from UPMC hospitals are three times higher than they were in March and April. He said patients are also getting better faster and the mortality rates are trending down.

“We think the answer is (to why the results are better) because of how we care for the patients,” he said.

Yearly said even though the results are better, it doesn’t mean COVID-19 is going away and people will need to continue adapting to live with the virus, which includes wearing a mask that covers both your nose and mouth, staying home if you feel ill and washing your hands frequently.

“It’s something we will continue to do for many months,” he said.

The doctors were asked if the virus has less of a viral load and patients are getting better if it is necessary for people to still wear a mask. Yealy said the most important thing people can do to protect themselves and others is to wear a mask. He said if people cannot master the task of wearing a mask, and wearing it right, the economic shutdown that occurred earlier this year may happen again.

“The masks absolutely matter,” he said. “The mask is probably the single biggest reason for (for improved results).”

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