How Doctors Are Getting Better At Treating Covid-19

Knowledge matters. Lessons learned and information shared are improving outcomes and reducing mortality.

That can help hold the line on treatment until better drugs and a vaccine are ready. JL

Margherita Stancati and Jason Douglas report in the Wall Street Journal:

Those dying from Covid-19 in intensive care declined to 42% by late May, from 60% in March. Daily clinical experience in hard-hit areas such as Italy and the U.K. as well as rapid scientific research have combined to produce the outline of a treatment strategy—which includes a mix of anti-inflammatory drugs and blood thinners—that doctors say is saving lives among those hospitalized and the smaller number who need intensive care.“Time and again, combination (drug) treatments have shown to be superior, even when a single one has little or no efficacy.”

When the new coronavirus swept into northern Italy in late February, doctors were so in the dark about how to treat the disease ravaging their patients they asked friends in China to translate clinical guidelines from Mandarin they had found online.

“There was everything in there, including traditional Chinese medicine,” recalls Marco Rizzi, the head of the infectious-diseases ward at Papa Giovanni XXIII hospital in Bergamo, a city at the center of Italy’s outbreak. “Now we have more cards to play.”

Doctors in Europe say progress in treating people with Covid-19 is helping to reduce fatalities among the sickest patients, a hopeful sign as the region grapples with sporadic flare-ups as it heads through the tourist season and into fall and winter.

Daily clinical experience in hard-hit areas such as Italy and the U.K. as well as rapid scientific research have combined to produce the outline of a treatment strategy—which includes a mix of anti-inflammatory drugs and blood thinners—that doctors in Europe say is saving lives among those hospitalized and the smaller number who need intensive care.

A Different Disease

Covid-19 patients have required longer ICU

stays, more interventions, and have had

higher death rates compared with typical

viral pneumonia patients.

Covid-19 patients

Non-Covid

Median days in ICU*

12 days

6

Share of patients requiring ventilators†

72%

48

Needing kidney support

(such as dialysis)

27%

17

Who died

40%

21

*For patients who recover; †Defined as advanced respiratory support. Note: U.K. data, for 10,228 Covid-19 ICU patients through July 23, and 5,626 non-Covid viral pneumonia ICU patients, 2017–2019

Source: Intensive Care National Audit and
Research Center

“We are doing better,” said Tim Cook, an anesthesiology consultant and honorary professor at the University of Bristol. “But it’s a horrible disease.”

Most cases of Covid-19 are mild and can be treated at home with rest, fluids and common painkillers. But in Europe, around a third of known cases end up in hospital, the European Centre for Disease Prevention and Control estimates.

An analysis of multiple studies world-wide by Mr. Cook and colleagues at the University of Bristol found the proportion of those dying from Covid-19 in intensive care declined to 42% by late May, from around 60% in March, when the pandemic was at its most intense. Mortality rates are similar for Europe, Asia and North America, the study found.

Better treatment is important but not the only factor driving that improvement, doctors say. Far fewer people are getting infected than at the peak of the crisis, and more of those who are infected are younger, which may contribute to better outcomes. Health systems are also better prepared and less stressed than at the height of the pandemic.

Almost 1.7 million coronavirus cases have been reported in Europe since the pathogen was first detected on the continent in January, according to the ECDC. More than 180,000 virus-linked deaths have been recorded, with the deadliest outbreaks in the U.K., France, Spain and Italy.

Recent days have seen fresh bursts of infection detected in parts of Spain and Eastern Europe, fueling worries about a new wave of infection. Should a second wave sweep through the continent, doctors say they are better prepared to treat patients who will need hospital care. Crucially, doctors now know that Covid-19 isn’t just a respiratory disease but that it can potentially affect the cardiovascular and nervous systems, for instance.

The emerging approach focuses on treating a handful of frequently observed symptoms of severe Covid-19 that can turn deadly. First is delivering enough oxygen. Second is reducing the risk of blood clots. Third is tackling inflammation of the organs and tissues caused by a runaway immune response to the virus. Doctors say some patients also need treatment for kidney failure.

The wide range of symptoms in severe cases, and the lingering damage suffered by many who recover, distinguishes Covid-19 from comparable respiratory illnesses, said Daniele Bryden, a senior intensive-care physician in the U.K. and vice dean of Britain’s Faculty of Intensive Care Medicine. “It’s very strange, this disease,” she said.

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While mechanical ventilation to improve patients’ oxygen supply was standard practice among severely sick patients early on, doctors say they have learned to avoid it unless absolutely necessary. Instead, many patients are given oxygen at high pressure using sophisticated plastic hoods. They are also laid on their stomachs, a technique known as proning that boosts lung function.

When the new coronavirus ravaged northern Italy in late February, doctors were only beginning to notice that Covid-19 patients were at high risk of blood clots. The Chinese guidelines they read, for instance, made no mention of potential cardiovascular complications.

Doctors in the region of Lombardy were among the first to start using blood thinners such as heparin on Covid-19 patients, a practice that has spread across Europe. Doctors prescribe prophylactic doses of blood thinner to patients when they first enter hospital, and higher quantities to more severely sick patients.

“We learned to make the most of the tools we had,” said Camillo Rossi, who oversees the medical staff at Spedali Civili, a hospital in Lombardy’s city of Brescia that has treated some 3,000 Covid-19 patients. “And we learned to work together, across medical disciplines.”

Doctors at Spedali Civili and other European hospitals learned early on about the benefits of another drug: dexamethasone, a cheap steroid now widely used on Covid-19 patients with serious respiratory problems.

A large clinical trial in the U.K. called Recovery recently showed that dexamethasone reduced deaths by up to a third among very sick patients receiving oxygen. The study has enrolled more than 11,500 patients at 175 hospitals to test a variety of potential treatments for Covid-19 in a randomized controlled trial, the gold standard approach in medical research.

Recovery has reported two other main findings so far. It found that hydroxychloroquine, an antimalarial drug touted as a weapon against the coronavirus by President Trump, among others, has zero benefit for Covid-19 patients. It reported similarly disappointing results for lopinavir and ritonavir, a combination commonly used to treat HIV.

It is currently evaluating treatments including blood plasma taken from convalescent Covid-19 patients, azithromycin, an antibiotic, and an arthritis medication called tocilizumab.

In Italy, hospitals are already using tocilizumab to suppress the overreaction of the immune system—known as a cytokine storm—in severely sick Covid-19 patients to prevent the need for mechanical ventilation. Although there is some evidence it may work, there still is no conclusive scientific proof of its benefits.

What doctors say they lack are effective drugs against the virus itself that can be given early in the course of the disease to halt its progression and reduce symptoms. The only antiviral to show proven benefit in a clinical trial is remdesivir, developed to treat hepatitis C. The European Union this week announced a deal with Gilead Sciences Inc. for supplies of the drug, which is expensive and not widely available.

Even better would be a workable vaccine, doctors say. Dozens are in tests.

Babak Javid, associate professor in experimental medicine at the University of California, San Francisco, said doctors also need robust data on which cocktail of drugs is most effective. “Time and again, combination treatments have shown to be superior, even when a single one has little or no efficacy,” he said.