Job Security -
Hes commenting of the fact there is no control. He says no control cause we are proposing to treat everyone.
Also says what about the hippocratic oath. I always wondered about the ethics of giving someone near death or on a path to death a fucking placebo!
Good point but I'm not necessarily arguing to give controls placebo (although plenty of people are, they remain completely unimpressed with HCQ). At this point, no ethics committee would sign off on this. HCQ has risks and I could make an argument for clinical equipose, but I'm ok to accept HCQ as a treatment.
Could be HCQ vs HCQ + azithro. Or HCQ vs Remdesivir.
Here in Denmark the COVID-19 guidelines that just came out yesterday say nothing of antiviral treatment except that they will update them as soon as evidence becomes available, and I think there’s a study starting next week with a clean placebo group vs HCQ. Both the study and the guidelines are not targetted at ICU-patients though. HCQ and azithromycin have been made off-limits to prescribe for doctors outside of hospitals/specialist clinics though, so somebody must have been prescribing it off-label.
I just read there’s a global shortage of condoms coming up due to factory shutdowns. Without azithromycin for GPs we’ll soon have a chlamydia pandemic on our hands as well :)
Don't you find it weird that HCQ vs placebo wouldn't be tried on sick patients?
First, I'm assuming you'd need A LOT of patients to see a difference in outcomes in mildly sick individuals.
Second, doesn't it say something about our presumed interpretation of equipose?
Ah, I worded myself inaccurately regarding the guidelines: they were published by the danish college of pulmonologists and specify treatment of in-hospital patients outside of ICU units. The intensivist college hasn’t published a guideline (I’m guessing it’s because there is no evidence to support such a guideline, and they’d rather allow for individual assessments and for practice to be adapted to local conditions in the critically ill patients).
Regarding studies and equipoise, I don’t know in the case of COVID-19. It might turn out like Tamiflu and Influenza where you couldn’t show an effect of treatment in studies unless initiated shortly after symptom onset, which was rarely the case in studies based in ICU settings, so the evidence had to be based on study populations with milder presentations (IIRC, and that might have changed, I haven’t reviewed the literature in years). This is obviously an exception to the rule and speculation on my part - in general you’re right: studying the most severely sick would be the best way of making a feasible effect study. The study I was thinking of was part of a multinational one with I think 600 patients in each treatment arm (SoC, HCQ, remdesivir, lopinavir). That might be too few for statistical significance, but probably enough to get an estimate if any of the treatments have an impact of clinical significance.
Now, there’s one study planned here, for which I absolutely agree with you that it’s dumb as bricks: they’re planning to do an RCT with HCQ on covid-19 patients not admitted to a hospital AND their close household contacts in 50 families. I’ve only read about it in the media though, and it seems to be motivated by a GP who had started prescribing HCQ to vulnerable groups in his practice. It might be just a way for reaearchers/authorities to a least formalize that (mal)practice. Or to drag out time with false promises while shutting him up, I don’t know. Seems hopelessly underpowered to show anything but side-effects to me at least.
Regarding equipoise I’m probably more worried about all those small, quickly-set-up studies with non-PIOs which might skew it and make it harder to set up the big studies of PIOs. I’m doing observational studies though, and have little experience with intervention studies, so that’s somewhat of an uninformed opinion on my part.